Utilization Management Rep I
Core
Coordinates cases for precertification and prior authorization review, managing incoming claims and determining benefit eligibility for inpatient and outpatient services.
Role type
Utilization Management Representative
Builds
Prior authorization decisions and clinical screening outcomes for healthcare plans
Domain
Health insurance / Utilization Management
Required skills
Customer service, call center operations, data entry, clinical screening, benefit eligibility determination, 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; authorizing inpatient admission and outpatient precertification; referring cases for clinical review; entering referral requests into the UM system; responding to inquiries from clients and providers; conducting clinical screening; authorizing initial session sets; checking benefits for facility-based treatment.
Seniority
Entry-level, non-management