Title: Utilization Management Representative I

Location: This position will work a hybrid model (remote and office). Ideal candidates will live within 50 miles of one of our PulsePoint locations.

The Utilization Management Representative I will be responsible for coordinating cases for precertification and prior authorization review.

How you will make an impact:

• Managing incoming calls or incoming post services claims work.

• Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests.

• Refers cases requiring clinical review to a Nurse reviewer.

• Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.

• Responds to telephone and written inquiries from clients, providers and in-house departments.

• Conducts clinical screening process.

• Authorizes initial set of sessions to provider.

• Checks benefits for facility based treatment.

• Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.

Minimum Requirements

• HS diploma or GED

• Minimum of 1 year of customer service or call-center experience; or any combination of education and experience which would provide an equivalent background.

Preferred Qualifications

• Medical terminology training and experience in medical or insurance field preferred.

• Able to work a 8 hour shift between 11:30am - 8pm EST Monday - Friday highly preferred.

For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.