Utilization Management Representative I

Elevance Health (Anthem); Winston-Salem (NC); Hybrid; USD 42,000 - 54,000; Full time

Benefits offered by this job

Medical, dental, vision

401(k) matching

Paid holidays

Paid time off

Incentive bonus programs

Job summary

Elevance Health in Winston-Salem, NC is seeking an Utilization Management Representative I. The role can be work-from-home with required in-person training and occasional office presence within a commuting distance.

You will coordinate precertification and prior authorization reviews for care, manage calls and claims, and determine eligibility for services. Applicants should have a HS diploma or GED and at least 1 year of customer service or call‑center experience.

Qualifications

• Requires HS diploma or GED and at least 1 year of customer service or call-center experience.
• Medical terminology knowledge preferred.
• Strong oral, written and interpersonal communication skills.

Responsibilities

• Coordinate cases for precertification and prior authorization review.
• Manage incoming calls and post-service claims work.
• Determine contract and benefit eligibility; authorize inpatient, outpatient precertification, prior authorization and post-service requests.
• Refer cases requiring clinical review to a Nurse reviewer.
• Enter referral requests into the UM system accurately.
• Respond to inquiries from clients, providers and internal teams.
• Maintain positive customer relations and collaborate across functions.
• Multi-task across calls, messages, and queues while documenting notes.

Skills

Customer service

Medical terminology

Oral communication

Interpersonal skills

Analytical thinking

Education

HS diploma or GED

Job description

Anticipated End Date: 2026-11-17

Position Title:

Utilization Management Representative I

Job Description:

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.

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.
• 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.

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 & 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

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.

Benefits

• 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 l