Utilization Management Representative I
DescriptionSHIFT: Day Job
Responsible for managing incoming calls, including triage, opening of cases and authorizing sessions.
Primary duties may include, but are not limited to:
- 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.
- Obtains intake (demographic) information from caller.
- Conducts a thorough radius search in Provider Finder and follows up with provider on referrals given.
- Refers cases requiring clinical review to a nurse reviewer; and handles referrals for specialty care.
- Processes incoming requests, collection of information needed for review from providers, utilizing scripts to screen basic and complex requests for precertification and/or prior authorization.
- Verifies benefits and/or eligibility information.
- May act as liaison between Medical Management and internal departments.
- Responds to telephone and written inquiries from clients, providers and in-house departments.
- Conducts clinical screening process.
- Requires HS diploma or equivalent; 1 year customer service experience in healthcare related setting and medical terminology training; or any combination of education and experience, which would provide an equivalent background.
- For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Certain contracts require a Master's degree.
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.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.
Please be advised that Anthem only accepts resumes from agencies that have a signed agreement with Anthem. Accordingly, Anthem is not obligated to pay referral fees to any agency that is not a party to an agreement with Anthem. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Anthem.