Utilization Management Representative I (Idaho)
Virtual: 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.
The Utilization Management Representative I 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.
Minimum Requirements:
- 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.
Preferred Skills, Capabilities and Experiences:
- Medical terminology training and experience in medical or insurance field preferred.