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Clinical Services Specialist
2 months ago
Job Summary:
Elevance Health is seeking a skilled Utilization Management Representative I to join our team. As a key member of our operations team, you will play a critical role in ensuring the smooth coordination of cases for precertification and prior authorization review.
Key Responsibilities:
- Manage incoming calls and post-service claims work, providing timely and accurate responses to clients, providers, and internal departments.
- Determine contract and benefit eligibility, authorizing inpatient admissions, outpatient precertifications, prior authorizations, and post-service requests.
- Refer cases requiring clinical review to a Nurse reviewer, ensuring seamless coordination and communication.
- Identify and data-enter referral requests into the UM system, adhering to plan certificate guidelines.
- Develop and maintain positive customer relationships, coordinating with various functions within the company to ensure timely and effective issue resolution.
Requirements:
- High School diploma or equivalent.
- Minimum of 1 year of customer service or call-center experience, or any combination of education and experience providing equivalent background.
Preferred Skills:
- Medical terminology training and experience in the medical or insurance field.
- Familiarity with FHPS experience.
- Strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
About Elevance Health:
Elevance Health is a leading healthcare company dedicated to delivering high-quality, patient-centered care. Our team is passionate about making a positive impact on the lives of our customers and communities.
