Utilization Management II
Core
Managing incoming calls, triaging cases, and authorizing inpatient admissions, outpatient precertification, and prior authorizations for specialty pharmacy services.
Role type
Utilization Management Representative
Builds
Authorization decisions for specialty medication treatments
Domain
Healthcare / Insurance / Specialty Pharmacy
Required skills
Medical terminology, Customer service, Data entry, Provider communication, Benefit verification, Clinical screening
Preferred skills
Excel, Problem-solving, Analytical skills
Responsibilities
Manage incoming calls and post-service claims; 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