Utilization Management Representative I

Utilization Management Representative I

This role enables associates to work virtually full-time, with the exception of 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. 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 an accommodation is granted as required by law. You will be assigned an 8.5 hour shift between 8 AM and 6 PM Eastern.

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.
• Additional expectations to include but not limited to : 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 Requirements

Preferred Skills, Capabilities And Experiences

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.

For candidates working in person or virtually in the below location(s), the salary

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).

The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.