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Utilization Management Coordinator

2 months ago

Louisville, Kentucky, United States Elevance Health Full time

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.
  • Respond to telephone and written inquiries from clients, providers, and internal departments, providing exceptional customer service.
  • Conduct clinical screening processes, authorizing initial sessions with providers, and checking benefits for facility-based treatment.
  • 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 and Qualifications:

  • 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.

Work Environment:

This role will work a hybrid model, with a combination of remote and office work. Ideal candidates will live within 50 miles of one of our PulsePoint locations.