Utilization Management Representative I

Elevance Health•Durham, NC

9d•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, 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 in accordance with the plan certificate, responds to telephone and written inquiries, conducts clinical screening, authorizes an initial set of sessions to providers, and checks benefits for facility-based treatment. The role also maintains positive customer relations and coordinates across company functions so customer requests and questions are addressed appropriately and in a timely manner. This position is listed as virtual full-time, with required in-person training sessions; the description says alternate locations may be considered for candidates within commuting distance of an office. Remote training lasts two weeks, followed by a regular schedule, with availability required during operational hours and possible schedule variation based on business needs. The role requires multitasking in a fast-paced, high-pressure environment and may involve occasional overtime or schedule flexibility, as well as working from the office when necessary.

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.
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.
Ability to maintain focus during extended periods of sitting and handle multiple tasks in a fast-paced, high-pressure environment.
Availability to work within operational hours of 6:00 AM to 5:30 PM Mountain Time, with schedules potentially varying based on business needs.

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

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 an 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 in a timely manner.
Handle calls, texts, facsimiles, and electronic queues while 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, and work from the office as necessary.
Perform other duties as assigned.