Utilization Management Rep I

Elevance Health; Seven Fields (Butler County); Remote; USD 45,000 - 65,000; Full time

Job summary

Elevance Health is seeking an Utilization Management Representative I to coordinate precertification and prior authorization reviews. The role is remote with occasional in-person training sessions and flexible scheduling to support work-life balance.

You will manage calls, determine eligibility, authorize initial sessions, and refer complex cases to nurses. Strong communication, empathy, and multitasking are essential in a fast-paced environment.

Qualifications

• Minimum 1 year of customer service or call-center experience.
• Medical terminology training or insurance field exposure preferred.

Responsibilities

• Coordinate cases for precertification and prior authorization reviews.
• Handle incoming calls and inquiries from clients, providers, and internal teams.
• Determine contract and benefit eligibility and authorize inpatient or outpatient services as appropriate.
• Refer cases requiring clinical review to a Nurse reviewer.
• Enter referral requests into the UM system accurately and timely.
• Maintain positive customer relations and collaborate with company functions to resolve questions.

Skills

Customer service

Communication skills

Multitasking

Empathy

Education

HS diploma or GED

Tools

UM system

Job description

Shift: Monday-Friday

Utilization Management Representative I

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

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.

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.