Utilization Management Representative I
Core
Coordinating cases for precertification and prior authorization review, determining contract and benefit eligibility, and conducting clinical screening for inpatient and outpatient services.
Role type
Utilization Management Representative (IC)
Builds
Prior authorization decisions and clinical screening outcomes for healthcare plans
Domain
Healthcare / Insurance
Required skills
Customer service, call center operations, medical terminology, data entry, clinical screening, benefit verification, contract interpretation
Preferred skills
Inbound call center experience, medical or insurance field experience, URAC accreditation competencies
Responsibilities
Managing incoming calls and post-service claims, determining eligibility and providing authorization for admissions and treatments, referring cases for clinical review, entering referral data into UM systems, responding to inquiries from clients and providers, conducting clinical screening, authorizing initial therapy sessions, checking benefits for facility-based treatment
Seniority
Entry-level, Non-Management