Utilization Management Representative II
Core
Manage incoming calls for triage, case opening, and prior authorization decisions for specialty infusion therapies and high-cost biologics.
Role type
Utilization Management Representative (Claims Operations)
Builds
Prior authorization approvals and denial follow-ups for specialty pharmacy claims
Domain
Healthcare / Insurance / Specialty Pharmacy
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Medical terminology, customer service, contract and benefit eligibility verification, provider referral coordination, clinical screening documentation, payer criteria review
Preferred skills
HCPCS J-codes, ICD-10 coding, InterQual/MCG guidelines, EMR systems (Epic, WebRx), prior authorization portals (CoverMyMeds, Availity), Medicare/Medicaid/PBM models
Responsibilities
Manage incoming calls for triage and case opening; Determine contract and benefit eligibility; Obtain intake demographic information; Conduct provider searches and follow-ups; Refer cases requiring clinical review; Process requests and review supporting documentation; Verify benefits and coordinate with insurance/PBMs; Respond to inquiries and communicate authorization status; Document authorization details in the system