Utilization Management Representative

Anticipated End Date:

Position Title:

Utilization Management Representative I

Job Description:

Location:

The selected candidate for this position must reside in Lake Mary, Tampa or Miami Florida.

Hours:

Must be available to work 4 days between Monday - Friday from 8:30 am - 5 pm EST + one weekend day per week.

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-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.

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

• 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.
• Authorizes initial set of sessions to provider and 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.

Requires HS diploma or GED and a minimum of 1 year of customer service or call-center experience; or any combination of education and experience which would provide an equivalent background.

• Medical terminology training and experience in medical or insurance field preferred.
• Experience with Medicaid waiver programs or other Medicaid utilization management experience preferred.

Non-Management Non-Exempt

2nd Shift (United States of America)

CUS >
Care Support

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We…