Utilization Management Representative II (Virtual in Ohio)

CareBridge • Independence, OH

82d

About The Position

The Utilization Management Representative II position is designed for individuals who are responsible for managing incoming calls, including triage, opening of cases, and authorizing sessions. This role is part of the MyCare Ohio health plan, which aims to deliver high-quality, trauma-informed, culturally competent, person-centered coordination for all members, addressing physical health, behavioral health, long-term services and supports, and psychosocial needs. The position allows for virtual work full-time, with the exception of required in-person training sessions, promoting productivity and work-life integration.

Requirements

• High school diploma or GED equivalent.
• Minimum of 2 years customer service experience in a healthcare-related setting.
• Medical terminology training or equivalent background.

Nice To Haves

• Experience with LTSS support or waivers strongly preferred.
• Health plan knowledge (prior authorizations experience) strongly preferred.
• Flexibility and strong attention to detail preferred.
• Strong oral, written, and interpersonal communication skills.
• Problem-solving, facilitation, and analytical skills preferred.

Responsibilities

• Manage incoming calls, including triage, opening of cases, and authorizing sessions.
• Determine contract and benefit eligibility; provide authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests.
• Obtain intake (demographic) information from callers.
• Conduct thorough radius searches in Provider Finder and follow up with providers on referrals given.
• Refer cases requiring clinical review to a nurse reviewer; handle referrals for specialty care.
• Process incoming requests and collect information needed for review from providers.
• Utilize scripts to screen basic and complex requests for precertification and/or prior authorization.
• Verify benefits and/or eligibility information.
• Act as a liaison between Medical Management and internal departments.
• Respond to telephone and written inquiries from clients, providers, and in-house departments.
• Conduct clinical screening processes.

Benefits

• Merit increases.
• Paid holidays.
• Paid Time Off.
• Incentive bonus programs.
• Medical, dental, and vision benefits.
• Short and long-term disability benefits.
• 401(k) with match.
• Stock purchase plan.
• Life insurance.
• Wellness programs.
• Financial education resources.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Ambulatory Health Care Services
• Education Level: High school or GED
• Number of Employees: 251-500 employees