Utilization Management Representative I
Core
Coordinates cases for precertification and prior authorization review, managing incoming calls and post-service claims.
Role type
Utilization Management Representative
Builds
Prior authorizations, inpatient/outpatient precertifications, and post-service requests for health plans.
Domain
Health Insurance / Utilization Management
Required skills
Customer service, call center operations, data entry, contract interpretation, benefit eligibility determination, multi-tasking, telephone communication, written communication, digital tools proficiency
Preferred skills
Medical terminology, Medicaid waiver programs, Medicaid utilization management
Responsibilities
Managing incoming calls and post-service claims; determining contract and benefit eligibility; providing authorization for inpatient admission, outpatient precertification, and prior authorization; referring cases requiring clinical review; identifying and entering referral requests into the UM system; responding to inquiries from clients, providers, and internal departments; authorizing initial session sets and checking benefits for facility-based treatment.
Seniority
Entry-level, Non-Management Non-Exempt