Utilization Management Rep I

Elevance Health; United States; Remote; USD 42,000 - 54,000; Full time

Job summary

Elevance Health is seeking a Utilization Management Representative I in a virtual capacity, with in-person training as required. The role coordinates precertification and prior authorization reviews, handles calls and claims work, and collaborates with Nurse reviewers to ensure timely, accurate decisions for member care.

Ideal candidates will have at least a HS diploma or GED and 1 year of customer service experience, with strong communication, empathy, and multitasking abilities for a

Qualifications

• HS diploma or GED required.
• 1 year of customer service or call-center experience or equivalent background.

Responsibilities

• Manage incoming calls and post-service claims work.
• Determine contract and benefit eligibility and authorize inpatient/outpatient precertification, prior authorization, and post-service requests.
• Refer cases needing clinical review to a Nurse reviewer.
• Enter referral data into the UM system per plan certificate.
• Respond to inquiries from clients, providers, and in-house departments.
• Conduct clinical screening and authorize initial provider sessions.
• Verify benefits for facility-based treatment.
• Maintain positive customer relations and coordinate across functions.

Skills

Customer service

Communication

Multitasking

Empathy

Problem-solving

Attention to detail

Education

HS diploma or GED

Tools

UM system

Job description

Anticipated End Date:

2026-10-30

Position Title:

Utilization Management Rep I

Job Description:

Utilization Management Representative I

Shift: Monday-Friday

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 and presented.

• 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.

Job Level:

Non-Management Non-Exempt

Workshift:

1st Shift (United States of America)

Job Family:

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.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

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 operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

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 should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact. 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.

NOTE:

Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words - the job is posted until 3/13, not through 3/13.