Utilization Management Representative – Backoffice Support

Utilization Management Representative I – Backoffice Support

Location :
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.

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 accommodation is granted as required by law.

Hours: Monday through Friday. Candidates must be available to work an assigned shift between 8:00 a.m. and 8:00 p.m. Eastern Time , based on business needs.

The Behavioral Health Utilization Management Representative I – Backoffice Support is responsible for processing precertification, prior authorization, and post-service requests for governmental and commercial lines of business. This is primarily a back of office role with no inbound call responsibilities. Limited outbound calls may be required to obtain information or support case resolution.

• Reviews and processes utilization management requests received through fax, electronic queues, and other approved channels.

• Accurately enters referral and authorization information into utilization management systems.

• Prepares and sends clear, complete, and accurate fax correspondence to providers, facilities, members, and internal partners.

• Meets departmental productivity, quality, accuracy, and turnaround-time standards while maintaining a low error rate.

• Reviews documentation for completeness and refers cases requiring clinical review to the appropriate clinical reviewer.

• Verifies benefits and administrative requirements within the scope of the role.

• Documents all actions and correspondence accurately and completely.

• Demonstrates accountability and ownership of assigned workload by monitoring queues, prioritizing tasks, following work through completion, and escalating barriers promptly.

• Protects confidential information and complies with HIPAA, privacy and security requirements, company policies, accreditation standards, contractual obligations, and applicable federal and state regulations.

• Identifies and reports potential quality, privacy, compliance, or regulatory concerns through established escalation processes.

• 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.

• 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

• 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.

• 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…