Utilization Management Representative I (Miami, FL)
Core
Coordinating cases for precertification and prior authorization review, managing incoming claims work, and conducting clinical screening processes to determine benefit eligibility and authorize treatments.
Role type
Utilization Management Representative
Builds
Prior authorization decisions and clinical screening outcomes for healthcare plans
Domain
Healthcare administration / Insurance utilization management
Deliverable
client delivery
Required skills
Customer service, data entry, telephone communication, clinical screening, benefit eligibility determination, contract interpretation
Preferred skills
Medical terminology, insurance field experience, bilingual communication
Technologies
UM system
Responsibilities
Managing incoming calls or post services claims work; determining contract and benefit eligibility; referring cases requiring clinical review to a Nurse reviewer; identifying and data entry of referral requests into the UM system; responding to inquiries from clients, providers and in-house departments; conducting clinical screening process; authorizing initial set of sessions to provider; checking benefits for facility based treatment.
Seniority
Entry-level, non-management