Utilization Management Representative I

Role Overview

• Coordinating cases for precertification and prior authorization review
• Managing incoming calls or incoming post services claims work
• Determining contract and benefit eligibility
• Providing authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests
• Referring cases requiring clinical review to a Nurse reviewer
• Responding to telephone and written inquiries from clients, providers and in-house departments
• Conducting clinical screening process
• Authorizing initial set of sessions to provider
• Checking benefits for facility based treatment
• Developing and maintaining positive customer relations

Requirements

• Requires HS diploma or GED and a minimum of 1 year of customer service or call-center experience
• Medical terminology training and experience in medical or insurance field preferred
• Experience with Medicaid waiver programs or other Medicaid utilization management experience preferred

Benefits

• Affordable Health Insurance
• Dental
• Vision
• Basic Life
• 401K match
• Paid Time Off
• Holiday Pay
• Annual incentive bonus and annual increases plan based on performance
• Opportunity for growth with further education reimbursement