Utilization Management Representative

Utilization Management Representative I

Location:

This role enables associates to work virtually full-time, with the exception of 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.

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.

Hours:

Working hours will be 10:30 AM to 7 PM Eastern. Training hours may vary. Training is 6 weeks and may require reporting to the nearest office.

• 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.

• 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.

• 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.
• This is a high volume inbound call center – strong time management skills and ability to function in a high volume environment is strongly preferred.

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 may contact elevancehealthj for assistance. 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.