Utilization Management Rep II (US)
Core
Manage incoming calls to triage, open cases, and authorize inpatient admissions, outpatient precertification, and prior authorization requests for healthcare members.
Role type
Utilization Management Representative
Builds
Authorization decisions for healthcare services
Domain
Healthcare / Insurance
Required skills
Medical terminology, customer service, data entry, provider communication, eligibility verification, clinical screening
Preferred skills
Master's degree, URAC accreditation competencies, complex case facilitation
Responsibilities
Manage incoming calls and triage requests; Determine contract and benefit eligibility; Conduct radius searches in Provider Finder; Refer cases requiring clinical review to nurse reviewers; Process requests using scripts to screen for precertification and prior authorization; Verify benefits and eligibility information; Respond to inquiries from clients, providers, and internal departments.