Utilization Management Representative I
Core
Coordinate cases for precertification and prior authorization review, managing incoming claims and determining benefit eligibility.
Role type
Utilization Management Representative I
Builds
Prior authorization decisions and clinical screening referrals
Domain
Healthcare administration / Insurance
Required skills
Customer service, Call center operations, Contract interpretation, Benefit eligibility determination, Clinical screening coordination, Multi-tasking
Preferred skills
Medical terminology, Medical or insurance field experience
Technologies
UM systems, Digital tools and platforms
Responsibilities
Manage incoming calls and post-service claims work, Provide authorization for inpatient admission and outpatient precertification, Refer cases requiring clinical review to a Nurse reviewer, Respond to inquiries from clients and providers, Conduct clinical screening process, Authorize initial set of sessions to provider, Check benefits for facility-based treatment
Seniority
Entry-level, Non-Management Non-Exempt