Utilization Management Representative – Backoffice Support

• Process precertification, prior authorization, and post-service requests for governmental and commercial lines of business
• Review and process utilization management requests received through fax, electronic queues, and other approved channels
• Enter referral and authorization information accurately into utilization management systems
• Prepare and send complete and accurate fax correspondence to providers, facilities, members, and internal partners
• Meet departmental productivity, quality, accuracy, and turnaround-time standards while maintaining a low error rate
• Review documentation for completeness and refer cases requiring clinical review to the appropriate clinical reviewer
• Verify benefits and administrative requirements within the scope of the role
• Document all actions and correspondence accurately and completely
• Monitor queues, prioritize tasks, follow work through completion, and promptly elevate barriers
• Protect confidential information and comply with HIPAA, privacy, security, company, accreditation, contractual, and regulatory requirements
• Identify and report potential quality, privacy, compliance, or regulatory concerns through established escalation processes
• Perform other duties as assigned
• Primarily perform back-office work with no inbound call responsibilities; make limited outbound calls when needed to obtain information or support case resolution

• High school diploma or GED
• Minimum of 1 year of customer service or call-center experience
• Any combination of education and experience providing an equivalent background
• Administrative support, healthcare operations, data entry, document processing, or back-office experience strongly preferred
• Medical terminology training and experience in medical or insurance field preferred
• Strong oral, written, and interpersonal communication skills
• Problem-solving skills
• Facilitation skills
• Analytical skills
• Ability to meet established productivity, quality, accuracy, compliance, and turnaround-time expectations preferred
• Ability to manage assigned work independently, maintain confidentiality, and follow detailed policies and procedures preferred
• Proficiency with computers, electronic work queues, email, and document-management systems preferred
• Experience processing faxes, referrals, authorizations, claims, medical records, or healthcare correspondence preferred
• Knowledge of HIPAA and healthcare privacy requirements preferred
• Experience working in a high-volume, production-based, compliance-focused environment preferred
• Availability to work an assigned Monday-Friday shift between 8:00 a.m. and 8:00 p.m. Eastern Time
• Must comply with HIPAA, privacy and security requirements, company policies, accreditation standards, contractual obligations, and applicable federal and state regulations
• New candidates in certain patient/member-facing roles must become vaccinated against COVID-19 and Influenza, unless an acceptable explanation is provided

Demonstrates proficiency in processing precertification, prior authorization, and post-service requests while adhering to HIPAA and regulatory requirements. Capable of managing tasks independently in a high-volume, compliance-focused environment with strong communication and problem-solving skills.

• Utilization Management
• HIPAA Compliance
• Data Entry
• Customer Service Experience
• Medical Terminology

• Precertification Processing
• Prior Authorization
• Document Processing
• Referral Management
• Claims Processing
• Healthcare Correspondence
• Analytical Skills
• Problem-Solving Skills
• Quality Assurance
• Compliance Managementi>