Utilization Management Representative I

About This Role

This role coordinates cases for precertification and prior authorization reviews by managing incoming calls or post-service claims work. It involves determining contract and benefit eligibility, referring cases for clinical review, and identifying and entering referral requests.

Responsibilities

• 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 data entry referral requests into the UM system
• 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

Requirements

• HS diploma or GED
• Minimum of 1 year of customer service or call-center experience

Qualifications

• HS diploma or GED
• Minimum of 1 year of customer service or call-center experience; or any combination of education and experience which would provide an equivalent background.

Nice to Have

• Medical terminology training and experience in medical or insurance field
• Call center and managed care experience

Skills

* Required skills

Benefits