Utilization Management Representative I

Elevance Health•Tampa, FL

22h•Remote

About The Position

The Utilization Management Representative I coordinates cases for precertification and prior authorization review. The role manages incoming calls and post-service claims work, checks contract and benefit eligibility, and provides authorization for inpatient admissions, outpatient precertification, prior authorization, and post-service requests. Cases requiring clinical review are referred to a Nurse reviewer. The representative identifies and enters referral requests into the utilization management system according to the plan certificate, responds to inquiries from clients, providers, and internal departments, and authorizes initial sessions while checking benefits for facility-based treatment. This role develops and maintains positive customer relationships and coordinates with company functions to resolve requests promptly. It requires multitasking across calls, texts, facsimiles, and electronic queues while taking notes and speaking with customers. The work includes extended periods of sitting and handling multiple tasks in a fast-paced, high-pressure environment. The selected candidate must reside in Lake Mary, Tampa, or Miami, Florida. The position is primarily virtual, with required in-person training and the ability to work in an office as needed. The work schedule is four days between Monday and Friday, 8:30 a.m.–5:00 p.m. EST, plus one weekend day per week; occasional overtime or schedule flexibility may be needed based on business needs.

Requirements

High school diploma or GED and at least one year of customer service or call-center experience, or an equivalent combination of education and experience.
Must reside in Lake Mary, Tampa, or Miami, Florida.
Must be available to work four days between Monday and Friday from 8:30 a.m. to 5:00 p.m. EST, plus one weekend day per week.
Ability to multitask and maintain focus during extended periods of sitting in a fast-paced, high-pressure environment.
Strong verbal and written communication skills in virtual and in-person interactions.
Attention to detail, critical-thinking, and problem-solving skills.
Empathy and persistence in resolving caller issues completely.
Comfort and proficiency using digital tools and platforms.

Nice To Haves

Medical terminology training and experience in the medical or insurance field.
Experience with Medicaid waiver programs or other Medicaid utilization management.

Responsibilities

Manage incoming calls and incoming post-service claims work.
Determine contract and benefit eligibility.
Provide authorization for inpatient admissions, outpatient precertification, prior authorization, and post-service requests.
Refer cases requiring clinical review to a Nurse reviewer.
Identify and enter referral requests into the utilization management system in accordance with the plan certificate.
Respond to telephone and written inquiries from clients, providers, and internal departments.
Authorize the initial set of sessions to providers and check benefits for facility-based treatment.
Develop and maintain positive customer relations and coordinate with company functions to handle customer requests and questions appropriately and promptly.
Handle calls, texts, facsimiles, and electronic queues while taking notes and speaking with customers.
Perform other duties as assigned.