Job Description
Utilization Management Representative I
Shift: Monday-Friday
Location: Virtual: This role enables associates to work virtually full-time, except for 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 accommodation is granted as required by law.
The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review.
How you will make an impact:
- 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.
- Associates in this role are expected to have the 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.
Minimum Qualifications:
- 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.
Preferred Skills, Capabilities and Experiences:
- Medical terminology training and experience in medical or insurance field 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.
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