Utilization Management Representative I

Elevance Health•Meridian, ID

7d•Remote

About The Position

The Utilization Management Representative I coordinates cases for precertification and prior authorization review. The role manages incoming calls or post-service claims work, determines 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 in accordance with the plan certificate, conducts clinical screening, authorizes an initial set of sessions to providers, and checks benefits for facility-based treatment. The representative responds to telephone and written inquiries from clients, providers, and internal departments, and coordinates with company functions to ensure requests and questions are handled appropriately and promptly. The work involves multitasking across calls, texts, facsimiles, and electronic queues while taking notes and speaking with customers. It requires sustained focus while sitting, effective communication in virtual and in-person interactions, attention to detail, critical thinking, problem-solving, empathy, and persistence. The role uses digital tools and platforms to improve productivity and reduce manual work. The position is primarily virtual, with required in-person training sessions and possible office work as needed. Training is remote for two weeks, from 7:00 AM to 3:30 PM Mountain Time. The regular schedule is 8:30 AM to 5:30 PM Mountain Time, with availability required during operational hours of 6:00 AM to 5:30 PM Mountain Time as schedules may vary with business needs. Occasional overtime or schedule flexibility may be required. The role may also perform other duties as assigned.

Requirements

High school diploma or GED, or an equivalent combination of education and experience.
At least 1 year of customer service or call-center experience, or an equivalent combination of education and experience.
Strong verbal and written communication skills for virtual and in-person interactions.
Attention to detail, critical-thinking, and problem-solving skills.
Ability to demonstrate empathy and persistence in resolving caller issues.
Ability to multitask in a fast-paced, high-pressure environment and maintain focus during extended periods of sitting.
Availability to work within operational hours of 6:00 AM to 5:30 PM Mountain Time, with occasional overtime or schedule flexibility based on business needs.
Ability to work from the office as necessary.

Nice To Haves

Medical terminology training.
Experience in a medical or insurance field.
For URAC-accredited areas: strong oral, written, and interpersonal communication, problem-solving, facilitation, and analytical skills.

Responsibilities

Coordinate cases for precertification and prior authorization review.
Manage incoming calls or incoming post-service claims work.
Determine contract and benefit eligibility.
Provide authorization for inpatient admission, outpatient precertification, prior authorization, and post-service requests.
Refer cases requiring clinical review to a Nurse reviewer.
Identify and enter referral requests into the UM system in accordance with the plan certificate.
Respond to telephone and written inquiries from clients, providers, and in-house departments.
Conduct the clinical screening process.
Authorize the initial set of sessions to providers.
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 simultaneously taking notes and speaking to customers.
Use digital tools and platforms to enhance productivity and minimize manual efforts.
Work a structured schedule with occasional overtime or flexibility based on business needs, including working from the office as necessary.
Perform other duties as assigned.