Utilization Management Representative I

1 month ago

Louisville, United States Elevance Health Full time

Title: Utilization Management Representative I

Location: This position will work a hybrid model (remote and office). Ideal candidates will live within 50 miles of one of our PulsePoint locations.

The Utilization Management Representative I will be 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.

Minimum Requirements

  • 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.

  • FHPS experience 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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