Utilization Management Representative II
Core
Managing incoming calls to triage, open cases, and authorize inpatient admissions, outpatient precertification, and prior authorizations for specialty pharmacy services.
Role type
Utilization Management Representative (IC)
Builds
Authorization decisions for specialty medication access and clinical review referrals
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, Provider communication, Data entry, Benefit verification, Clinical screening
Preferred skills
Excel (intermediate), Problem-solving, Analytical skills
Responsibilities
Manage incoming calls for triage and case opening; Determine contract and benefit eligibility; Obtain demographic information from callers; Conduct radius searches in Provider Finder; Refer cases requiring clinical review to nurse reviewers; Process requests for precertification and prior authorization using scripts; Verify benefits and eligibility information; Respond to inquiries from clients, providers, and internal departments.
Seniority
Individual Contributor, Entry to Mid-level