Utilization Review Nurse

Utilization Management Representative I Backoffice Support

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 accommodation is granted as required by law.

Hours: Monday through Friday. Candidates must be available to work an assigned shift between 8:00 a.m. and 8:00 p.m. Eastern Time, based on business needs.

The Behavioral Health Utilization Management Representative I Backoffice Support is responsible for processing precertification, prior authorization, and post-service requests for governmental and commercial lines of business. This is primarily a back of office role with no inbound call responsibilities. Limited outbound calls may be required to obtain information or support case resolution.

How you will make an impact:

• Reviews and processes utilization management requests received through fax, electronic queues, and other approved channels.
• Accurately enters referral and authorization information into utilization management systems.
• Prepares and sends clear, complete, and accurate fax correspondence to providers, facilities, members, and internal partners.
• Meets departmental productivity, quality, accuracy, and turnaround-time standards while maintaining a low error rate.
• Reviews documentation for completeness and refers cases requiring clinical review to the appropriate clinical reviewer.
• Verifies benefits and administrative requirements within the scope of the role.
• Documents all actions and correspondence accurately and completely.
• Demonstrates accountability and ownership of assigned workload by monitoring queues, prioritizing tasks, following work through completion, and escalating barriers promptly.
• Protects confidential information and complies with HIPAA, privacy and security requirements, company policies, accreditation standards, contractual obligations, and applicable federal and state regulations.
• Identifies and reports potential quality, privacy, compliance, or regulatory concerns through established escalation processes.
• Performs other duties as assigned.

Minimum Qualifications:

• 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:

• Administrative support, healthcare operations, data entry, document processing, or back-office experience strongly preferred
• 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.
• Ability to meet established productivity, quality, accuracy, compliance, and turnaround-time expectations preferred
• Ability to manage assigned work independently, maintain confidentiality, and follow detailed policies and procedures preferred
• Proficiency with computers, electronic work queues, email, and document-management systems preferred
• Experience processing faxes, referrals, authorizations, claims, medical records, or healthcare correspondence preferred
• Knowledge of HIPAA and healthcare privacy requirements preferred
• Experience working in a high-volume, production-based, compliance-focused environment preferred

Job Level: Non-Management Non-Exempt