Utilization Management Representative I
About The Position
This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. As a Utilization Management Representative I, you will be responsible for coordinating cases for precertification and prior authorization review. Associates in this role are expected to have the ability to multi-task, including handling calls, texts, facsimiles, and electronic queues, while simultaneously taking notes and speaking to customers. Additional expectations to include but not limited to: Proficient in maintaining focus during extended periods of sitting and handling multiple tasks in a fast-paced, high-pressure environment; strong verbal and written communication skills, both with virtual and in-person interactions; attentive to details, critical thinker, and a problem-solver; demonstrates empathy and persistence to resolve caller issues completely; comfort and proficiency with digital tools and platforms to enhance productivity and minimize manual efforts. Associates in this role will have a structured work schedule with occasional overtime or flexibility based on business needs, including the ability to work from the office as necessary. Performs other duties as assigned.
Requirements
- Requires HS diploma or GED and a minimum of 1 year of customer service or call-center experience; or any combination of education and experience which would provide an equivalent background.
- Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Nice To Haves
- Medical terminology training and experience in medical or insurance field preferred.
- Experience with Medicaid waiver programs or other Medicaid utilization management experience preferred.
Responsibilities
- Managing incoming calls or incoming post services claims work.
- Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests.
- Refers cases requiring clinical review to a Nurse reviewer.
- Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.
- Responds to telephone and written inquiries from clients, providers and in-house departments.
- Conducts clinical screening process.
- Authorizes initial set of sessions to provider.
- Checks benefits for facility based treatment.
- Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.
Benefits
- A career path with opportunity for growth.
- Ability to obtain your Associate’s or Bachelor’s degree or further your education with tuition reimbursement.
- Affordable Health Insurance, Dental, Vision and Basic Life.
- 401K match, Paid Time Off, Holiday Pay
- Annual incentive bonus and annual increases plan based on performance.
- comprehensive benefits package
- incentive and recognition programs
- equity stock purchase
- 401k contribution
- medical, dental, vision, short and long term disability benefits
- life insurance
- wellness programs
- financial education resources
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
