Utilization Management Representative I

The Elevance Health Companies, Inc.; Costa Mesa (CA); Hybrid; USD 22,000 - 38,000; Full time

Benefits offered by this job

Comprehensive benefits package

401k contribution

Stock purchase program

Incentive and recognition programs

Medical, dental, vision, disability

Job summary

Elevance Health is seeking a Utilization Management Representative I. This role supports managing calls, eligibility determinations, precertifications, and referrals to nurse reviewers. It allows virtual work with required in-person trainings and a hybrid/work-from-office option depending on location.

A structured schedule with occasional overtime and vaccination requirements may apply. This U/M role requires a HS diploma or GED and at least 1 year of customer service experience.

Qualifications

• HS diploma or GED is required.
• 1 year of customer service or call-center experience.
• Medical terminology training and experience in medical or insurance fields preferred.

Responsibilities

• Manage incoming calls and post services claims work.
• Determine contract and benefit eligibility; authorize inpatient admissions, precertification, prior authorization, and post-service requests.
• Refer cases requiring clinical review to a Nurse reviewer.
• Enter referral data into the UM system per plan certificate.
• Respond to inquiries from clients, providers and internal departments.
• Conduct clinical screening processes.
• Authorize initial set of sessions to providers.
• Check benefits for facility-based treatment.
• Maintain positive customer relations and coordinate across functions.
• Perform other duties as assigned.

Education

HS diploma or GED

Job description

Position Details

Anticipated End Date: 2026-11-07

Position Title: Utilization Management Representative I

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 an accommodation is granted as required by law.

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.
• Performs other duties as assigned.

Additional expectations

• 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.

Minimum Requirements

• 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.

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: strong oral, written and interpersonal communication skills, problem‑solving skills, facilitation skills, and analytical skills.

Salary and Locations

For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $15.96 to $27.53.

Locations: California, Illinois, Virginia.

Benefits

• comprehensive benefits package
• incentive and recognition programs
• equity stock purchase
• 401k contribution
• medical, dental, vision, short and long term disability benefits
• pay holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement)
• life insurance
• wellness programs and financial education resources
• stock purchase plan
• financial education resources

Job Details

• Job Level: Non-Management
• Non-Exempt
• Workshift:
• Job Family: CUS > Care Support

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.

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 follows all relevant federal, state and local laws.

Equal Employment Opportunity

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.

Accommodation for Applicants with Disabilities

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.

Legal and Regulatory Compliance

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.

Other

We also note that Elevance Health’s compensation is based on legitimate non‑discriminatory factors and the company fully commits to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.