Utilization Management Rep I
Core
Coordinating cases for precertification and prior authorization review, determining benefit eligibility, and conducting clinical screenings for inpatient and outpatient services.
Role type
Utilization Management Representative
Builds
Authorization decisions for inpatient admission, outpatient precertification, and prior authorization requests
Domain
Healthcare administration / Insurance
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Customer service, call center operations, data entry, clinical screening, benefit verification, telephone communication, written communication, multi-tasking, digital tools proficiency
Preferred skills
Medical terminology, insurance field experience, problem-solving, analytical skills
Responsibilities
Managing incoming calls and post-service claims; determining contract and benefit eligibility; referring cases requiring clinical review to a Nurse reviewer; identifying and entering referral requests into the UM system; responding to inquiries from clients, providers, and internal departments; authorizing initial sets of sessions to providers; checking benefits for facility-based treatment.
Seniority
Entry-level, non-management