Utilization Management Representative I

Elevance Health•Durham, NC

9d•$16 - $28•Remote

About The Position

The Utilization Management Representative I coordinates cases for precertification and prior authorization review. The position manages incoming calls and 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, responds to telephone and written inquiries, conducts clinical screening, authorizes initial sessions to providers, and checks benefits for facility-based treatment. The role also develops positive customer relations and coordinates with company functions to address customer requests accurately and promptly. This role is primarily virtual, with in-person training required and the ability to work from an office as needed. Candidates must be within a reasonable commuting distance of the posting location unless an accommodation is granted. The work includes a structured schedule, with occasional overtime or flexibility based on business needs.

Requirements

High school diploma or GED, and at least 1 year of customer service or call-center experience; or an equivalent combination of education and experience.
Ability to multitask in a fast-paced, high-pressure environment, including maintaining focus during extended periods of sitting.
Strong verbal and written communication skills for 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 with digital tools and platforms.

Nice To Haves

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

Responsibilities

Manage incoming calls and incoming post-service claims work.
Determine contract and benefit eligibility and provide authorizations 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 taking notes and speaking with customers.
Perform other duties as assigned.