Utilization Management Representative I (US)

Elevance Health; Latham (NY); Hybride; USD 23 000 - 38 000; Plein temps

Résumé du poste

Elevance Health is seeking a Utilization Management Representative I (US) to coordinate cases for precertification and prior authorization review. This role emphasizes collaborative work with nurse reviewers and providers to ensure timely and accurate decisions.

In a hybrid/remote setting with in-person training as needed, you will manage calls, determine eligibility, authorize services, and maintain strong client relationships.

Qualifications

• Minimum requirements: HS diploma or GED plus 1 year of customer service or call-center experience, or equivalent background.
• Preferred: medical terminology training and insurance industry exposure.
• URAC-related areas value strong communication, problem-solving, facilitation and analytical skills.

Responsabilités

• Manage incoming calls or post services claims work.
• Determine contract and benefit eligibility.
• Provide authorization for inpatient admission, precertification, prior authorization, and post-service requests.
• Refer cases requiring clinical review to a Nurse reviewer.
• Enter referral requests into the UM system per plan certificates.
• Respond to inquiries from clients, providers, and internal departments.
• Conduct clinical screening and authorize initial set of sessions.
• Check benefits for facility-based treatment.

Connaissances

Medical terminology training

Insurance field experience

Oral and written communication

Interpersonal skills

Problem-solving

Analytical skills

Facilitation

Formation

HS diploma or GED

Description du poste

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.

Utilization Management Representative I (US) will be responsible for coordinating cases for precertification and prior authorization review.

How You Will Make An Impact

• Manage incoming calls or incoming post services claims work.
• Determine contract and benefit eligibility.
• Provide authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests.
• Refer cases requiring clinical review to a Nurse reviewer.
• Identify and enter referral requests into the UM system in accordance with the plan certificate.
• Respond to telephone and written inquiries from clients, providers and in-house departments.
• Conduct clinical screening process.
• Authorize initial set of sessions to provider.
• Check benefits for facility based treatment.
• Develop and maintain positive customer relations and coordinate with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.
• Multi-task, including handling calls, texts, facsimiles, and electronic queues, while simultaneously taking notes and speaking to customers.
• Maintain focus during extended periods of sitting and handle multiple tasks in a fast-paced, high-pressure environment.
• Demonstrate strong verbal and written communication skills, both with virtual and in-person interactions.
• Apply attention to detail, critical thinking, and problem-solving skills to resolve issues.
• Demonstrate empathy and persistence to resolve caller issues completely.
• Use digital tools and platforms to enhance productivity and minimize manual efforts.
• Work a structured schedule with occasional overtime or flexibility based on business needs, including the ability to work from the office as necessary.
• Perform 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 And Experiences

• Medical terminology training.
• Experience in a medical or insurance field.
• For URAC accredited areas, strong oral, written and interpersonal communication skills, problem‑solving skills, facilitation skills, and analytical skills.

For candidates working in person or virtually in the below locations, the salary* range for this specific position is $16.76 to $27.53.

Location(s): California, Illinois, Minnesota, Nevada, New Jersey, New York, and Virginia

In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed 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.

• The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.