Utilization Management Rep

Utilization Management Representative I

Shift: Monday-Friday (Must be willing to work weekends and holidays)

Location:
Virtual: This role enables associates to work virtually full-time, except for 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.

Note:

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 accommodation is granted as required by law.

The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review.

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.

• 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 Qualifications:

• HS diploma or GED.

• Minimum of 1 year of customer service or call‑center experience; or any combination of education and experience which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences:

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

• 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.

We offer a range of market‑competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

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.

Applicants who require accommodation to participate in the job application process may contact elevancehealthj for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.