Utilization Management Rep I (US)
Core
Coordinating cases for precertification and prior authorization review, managing incoming claims work, and determining contract and benefit eligibility for inpatient and outpatient services.
Role type
Utilization Management Representative I
Builds
Prior authorizations, precertifications, and post-service requests for healthcare providers and members
Domain
Healthcare administration / Insurance
Deliverable
client delivery
Required skills
Medical terminology, data entry, clinical screening, multi-tasking, telephone communication, benefits verification
Preferred skills
Medical or insurance field experience, URAC professional competencies
Technologies
UM system, digital tools and platforms
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; conducting clinical screening processes; authorizing initial session sets to providers; checking benefits for facility-based treatment.
Seniority
Entry-level, non-management