Utilization Management Rep

Utilization Management Representative I

Virtual:
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. Alternate locations may be considered if candidates reside within a commuting distance from an office. 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.

• Coordinate cases for precertification and prior authorization review.
• Manage incoming calls or incoming post‑service claim work.
• Determine contract and benefit eligibility; provide authorization for inpatient admission, outpatient precertification, prior authorization, and post‑service requests.
• Refer cases requiring clinical review to a Nurse reviewer.
• Identify and 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 process and authorize initial set of sessions to provider.
• 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.
• Multi‑task, including handling calls, texts, facsimiles, electronic queues while taking notes and speaking to customers.
• Perform other duties as assigned.

• High school diploma or GED.
• Minimum 1 year of customer service or call‑center experience; or any combination of education and experience that provides an equivalent background.

• Medical terminology training and experience in a medical or insurance field.
• Strong oral, written and interpersonal communication skills, problem‑solving skills, facilitation skills, and analytical skills.

Shift: Monday‑Friday 10:30AM–7:00PM EST. Structured work schedule with occasional overtime or flexibility based on business needs, including the ability to work from the office as necessary.

Job Level: Non‑Management;
Non‑Exempt.

Work Shift:

2nd Shift (United States of America). Job Family: CUS >
Care Support.

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.