Utilization Management Representative Lead (Columbus, GA)

Elevance Health•Columbus, GA

4d•Remote

About The Position

The Utilization Management Representative Lead is responsible for providing technical guidance to UM Reps who handle correspondence and assist callers with issues concerning contract and benefit eligibility for precertification, prior authorization of inpatient and outpatient services and post service requests. This role enables associates to work virtually full-time, with the exception of 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.

Requirements

HS diploma or equivalent.
Minimum of 5 years related experience to include complex customer service or call center experience and medical terminology training; or any combination of education and experience which would provide an equivalent background.

Nice To Haves

Knowledge of health plans, including familiarity with prior authorization and precertification process preferred.
Knowledge of contracts and strong knowledge of managed benefit programs strongly preferred.
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.

Responsibilities

Motivates and encourages UM Reps while providing technical guidance.
Provides quality control services such as call monitoring and conducts UMR level I, II, and III audits for subsequent performance under NMIS and MTM standards.
Suggests methods to improve productivity.
Understands specific workflow, processes, departmental priorities and guidelines.
Monitors daily phone activities to exceed NMIS standards and improve customer service levels.
Assists in supervising the daily activities of a group of Behavioral Health Associates.
Provides direction and guidance to less experienced team members.
Assists manager with PTO scheduling and monitoring attendance.
Handles escalated and unresolved calls from less experienced team members.
Handles complex situations and ensures UM Reps are directed to the appropriate resources to resolve issues.
Keeps team members informed of any changes.
Assists management by identifying areas of improvement and recommends solutions.
Keeps manager informed of changes or problems.
Keeps departmental manuals up-to-date.
Researches resources for report generation for manager and ancillary departments.
Obtains, analyzes and presents statistical information as it relates to units of work, productivity, FTEs at work and time off.
May provide input into hiring decisions and performance appraisals.