Utilization Management Representative III

Elevance Health•Lake Mary, FL

1d•Remote

About The Position

The Utilization Management Representative III is responsible for coordinating cases for precertification and prior authorization review. This role provides technical guidance to UM Reps, assists callers with contract and benefit eligibility, and identifies areas for improvement. The representative handles escalated calls, ensures UM Reps are directed to appropriate resources, and explains workflow, processes, and guidelines. They may also assist in new hire training. Associates in this role must be able to multi-task in a fast-paced, high-pressure environment, handling calls, texts, facsimiles, and electronic queues while taking notes and speaking with customers. Additional expectations include maintaining focus during extended periods of sitting, strong verbal and written communication skills, critical thinking, problem-solving, empathy, persistence, and proficiency with digital tools.

Requirements

Requires a HS diploma or GED.
A minimum of 3 years of experience in customer service experience in a healthcare-related setting; or any combination of education and experience which would provide an equivalent background.
Medical terminology training required.

Nice To Haves

For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Certain contracts require a Master's degree.

Responsibilities

Coordinating cases for precertification and prior authorization review.
Providing technical guidance to UM Reps who handle correspondence and assist callers with issues concerning contract and benefit eligibility for requested continuing pre-certification and prior authorization of inpatient and outpatient services outside of initial authorized set.
Assisting management by identifying areas of improvement and expressing a willingness to take on new projects as assigned.
Handling escalated and unresolved calls from less experienced team members.
Ensuring UM Reps are directed to the appropriate resources to resolve issues.
Ability to understand and explain specific workflow, processes, departmental priorities and guidelines.
May assist in new hire training to act as eventual proxy for Ops Expert.
Exemplifies behaviors embodied in the 5 Core Values.
Ability to multi-task, including handling calls, texts, facsimiles, and electronic queues, while simultaneously taking notes and speaking to customers.
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.