Utilization Management Representative I

4 weeks ago

Cincinnati, Ohio, United States Elevance Health Full time

Job Summary:

Elevance Health is seeking a Utilization Management Representative I to join our team. In this role, you will be responsible for coordinating cases for precertification and prior authorization review.

Key Responsibilities:

  • Manage incoming calls and post-service claims work.
  • Determine contract and benefit eligibility, and provide authorization for inpatient admission, outpatient precertification, prior authorization, and post-service requests.
  • Refer cases requiring clinical review to a Nurse reviewer.
  • Identify and data-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 processes.
  • Authorize initial sets of sessions to providers.
  • 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.

Requirements:

  • HS diploma or GED.
  • Minimum of 1 year of customer service or call-center experience, or any combination of education and experience that would provide an equivalent background.

Preferred Skills:

  • Medical terminology training and experience in the medical or insurance field.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status, or any other status or condition protected by applicable federal, state, or local laws.

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