[Hiring] Utilization Management Representative I @Elevance Health

Role Description

The Utilization Management Representative I (US) will be responsible for coordinating cases for precertification and prior authorization review.

• Manage incoming calls or incoming post services 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 clinical screening process.
• Authorize initial set of sessions to provider.
• Check benefits for facility-based treatment.
• Develop and maintain positive customer relations and coordinate with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.
• Multi-task, including handling calls, texts, facsimiles, and electronic queues, while simultaneously taking notes and speaking to customers.
• Maintain focus during extended periods of sitting and handle multiple tasks in a fast-paced, high-pressure environment.
• Demonstrate strong verbal and written communication skills, both with virtual and in-person interactions.
• Apply attention to detail, critical thinking, and problem-solving skills to resolve issues.
• Demonstrate empathy and persistence to resolve caller issues completely.
• 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, including the ability to work from the office as necessary.
• Perform other duties as assigned.

Qualifications

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

Requirements

• Medical terminology training.
• Experience in a medical or insurance field.
• For URAC accredited areas, strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Benefits

• Comprehensive benefits package.
• Incentive and recognition programs.
• Equity stock purchase.
• 401k contribution (all benefits are subject to eligibility requirements).