Utilization Management Representative I

Utilization Management Representative I

Cincinnati, OH

Columbus, OH

Mason, OH

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.

Hours: Monday Friday, 8 AM - 5 PM EST

As a Utilization Management Representative I, you will be 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.

Here's what Elevance Health offers:

• A career path with opportunity for growth.
• Ability to obtain your Associate's or Bachelor's degree or further your education with tuition reimbursement.
• Affordable Health Insurance, Dental, Vision and Basic Life.
• 401K match, Paid Time Off, Holiday PayAnnual incentive bonus and annual increases plan based on performance.

At Elevance Health, the team is comprised of the best and the brightest from diverse experiences, cultures, and backgrounds. The differences we each bring to the table are a part of what makes our company so successful.

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.
• Experience with Medicaid waiver programs or other Medicaid utilization management experience preferred.