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Utilization Management Rep Ld

  • Job Family: Customer Care
  • Type: Full time
  • Date Posted:
  • Req #: JR55880


  • National +50 Miles away from nearest PulsePoint, National +50 Miles away from nearest PulsePoint



Responsible for performing customer service in a sales/account management environment. Responds to client issues via telephone and written correspondence regarding insurance benefits, provider contracts, eligibility, claims, etc. Follows appropriate policies and procedures. Responsible for providing technical guidance to UM Reps who handle correspondence and assist callers with issues concerning contract and benefit eligibility for precertification, prior authorization of inpatient and outpatient services and post service requests.

Primary duties may include, but are not limited to:

  • Motivates and encourages UM Reps while providing technical guidance.
  • Provides quality control services such as call monitoring and conducts UMR level I, II, and III audits for subsequent performance under NMIS and MTM standards.
  • Suggests methods to improve productivity. Understands specific workflow, processes, departmental priorities and guidelines.
  • Monitors daily phone activities to exceed NMIS standards and improve customer service levels.
  • Assists in supervising the daily activities of a group of Behavioral Health Associates.
  • Provides direction and guidance to less experienced team members.
  • Assists manager with PTO scheduling and monitoring attendance.
  • Handles escalated and unresolved calls from less experienced team members.
  • Handles complex situations and ensures UM Reps are directed to the appropriate resources to resolve issues.
  • Keeps team members informed of any changes. Assists management by identifying areas of improvement and recommends solutions.
  • Keeps manager informed of changes or problems.
  • Keeps departmental manuals up-to-date.
  • Researches resources for report generation for manager and ancillary departments.
  • Obtains, analyzes and presents statistical information as it relates to units of work, productivity, FTEs at work and time off.
  • May provide input into hiring decisions and performance appraisals.

For candidates working in person or remotely in the below locations, the salary* range for this specific position is $24.06-$25.39

Locations:  California; Colorado; Nevada; Washington State; Jersey City, NJ; New York City, NY; Ithaca, NY and Westchester County, NY

Qualifications - External

Minimum Requirements:

  • Requires HS diploma and a minimum of 5 years related experience to include complex customer service or call center experience and medical terminology training; or any combination of education and experience which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

  • Knowledge of health plans, including familiarity with prior authorization and precertification process; knowledge of contracts and strong knowledge of managed benefit programs strongly preferred.
  • Certain contracts require a Master's degree.
  • 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.

Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Be part of an Extraordinary Team

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. A Fortune 20 company with a longstanding history in the healthcare industry, we are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health has been named as a Fortune Great Place To Work in 2022, has been ranked for five years running as one of the 2023 World’s Most Admired Companies by Fortune magazine, and is a growing Top 20 Fortune 500 Company. To learn more about our company and apply, please visit us at Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact for assistance.

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