Utilization Management Representative I

Elevance Health • Roanoke, VA

428d

About The Position

The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review, ensuring that customer requests and inquiries are handled efficiently. This role involves managing incoming calls, determining contract and benefit eligibility, and authorizing various treatment requests while maintaining positive customer relations.

Requirements

• HS diploma or GED
• Minimum of 1 year of customer service or call-center experience; or any combination of education and experience which would provide an equivalent background.

Nice To Haves

• Medical terminology training and experience in medical or insurance field preferred.
• FHPS 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

• Merit increases
• Paid holidays
• Paid Time Off
• Incentive bonus programs
• Medical benefits
• Dental benefits
• Vision benefits
• Short and long term disability benefits
• 401(k) with matching
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Insurance Carriers and Related Activities
• Education Level: High school or GED
• Number of Employees: 11-50 employees