Utilization Management Representative I – Backoffice Support
HybridMiami, Florida, United States or Atlanta, Georgia, United States
Job Summary
Process precertification, prior authorization, and post-service requests for governmental and commercial lines of business via fax, electronic queues, and approved channels. Accurately enter referral and authorization information into utilization management systems while preparing clear correspondence for providers, facilities, members, and internal partners. Review documentation for completeness, refer cases requiring clinical review, and verify benefits and administrative requirements within the scope of the role. Maintain departmental productivity, quality, accuracy, and turnaround-time standards while documenting all actions and escalating barriers promptly.
Required Qualifications
- HS diploma or GED
- Minimum of 1 year of customer service or call-center experience
- any combination of education and experience which would provide an equivalent background
- Must be available to work an assigned shift between 8:00 a.m. and 8:00 p.m. Eastern Time
- Must be within a reasonable commuting distance from the posting location(s)
- Strong oral, written and interpersonal communication skills
- Problem-solving skills
- Facilitation skills
- Analytical skills
- Ability to meet established productivity, quality, accuracy, compliance, and turnaround-time expectations
- Ability to manage assigned work independently
- Ability to maintain confidentiality
- Ability to follow detailed policies and procedures
- Proficiency with computers, electronic work queues, email, and document-management systems
- Experience processing faxes, referrals, authorizations, claims, medical records, or healthcare correspondence
- Knowledge of HIPAA and healthcare privacy requirements
- Experience working in a high-volume, production-based, compliance-focused environment
- COVID-19 vaccination against COVID-19 and Influenza
Desired Qualifications
- Administrative support
- healthcare operations
- data entry
- document processing
- back-office experience
- Medical terminology training
- experience in medical or insurance field
- Experience in URAC accredited areas
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