Job Closed

This listing is no longer active.

Utilization Management Representative I

Customer AdvocateCustomer SuccessOtherRemoteMid LevelTeam 10,001+H1B SponsorCompany SiteLinkedIn

Location

United States

Posted

100 days ago

Salary

0

Seniority

Mid Level

No structured requirement data.

Job Description

Utilization Management Representative I

Elevance Health

Anticipated End Date: 2026-03-17 Position Title: Utilization Management Representative I Job Description: Utilization Management Representative I Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. 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. Here’s what Elevance Health offers: • A career path with opportunity for growth • Ability to obtain your Associate’s or Bachelor’s degree or further your education with tuition reimbursement. • Affordable Health Insurance, Dental, Vision and Basic Life • 401K match, Paid Time Off, Holiday Pay • Annual incentive bonus and annual increases plan based on performance. At Elevance Health, the team is comprised of the best and the brightest from diverse experiences, cultures, and backgrounds. The differences we each bring to the table are a part of what makes our company so successful. 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 Skills, Capabilities and Experiences - Medical terminology training and experience in medical or insurance field preferred. 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. Job Level: Non-Management Non-Exempt Workshift: 1st Shift (United States of America) Job Family: CUS > Care Support Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. 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. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. 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 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. 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 elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.

Related Job Pages

More Customer Advocate Jobs

OtherRemoteTeam 10,001+Since 1980H1B Sponsor

Career Category Sales Job Description Join Amgen’s Mission of Serving Patients At Amgen, if you feel like you’re part of something bigger, it’s because you are. Our shared mission—to serve patients living with serious illnesses—drives all that we do. Since 1980, we’ve helped pioneer the world of biotech in our fight against the world’s toughest diseases. With our focus on four therapeutic areas –Oncology, Inflammation, General Medicine, and Rare Disease– we reach millions of patients each year. Amgen is advancing a broad and deep pipeline of medicines to treat cancer, heart disease, inflammatory conditions, rare diseases, and obesity and obesity-related conditions. As a member of the Amgen team, you’ll help make a lasting impact on the lives of patients as we research, manufacture, and deliver innovative medicines to help people live longer, fuller happier lives. Our award-winning culture is collaborative, innovative, and science based. If you have a passion for challenges and the opportunities that lay within them, you’ll thrive as part of the Amgen team. Join us and transform the lives of patients while transforming your career. Patient Access Liaison What you will do Let’s do this. Let’s change the world. In this vital role you will provide logistical, non-medical educational assistance to patients and caregivers as well as office and site of care staff, including physicians, nurses, office managers and executives. Strong knowledge and demonstrated history of access and reimbursement for buy and bill/infused pharmaceutical products is required. The PAL works in highly visible, strong team environment to provide exceptional customer service on all levels. The PAL will work with the patient, the physician and the Site of Care to educate on next steps required to gain access to therapy. The PAL will also work to maintain relationships with patients and families, and by extension physicians and their staff and cross-functional partners to support ongoing compliance with therapy. The PAL will work with numerous internal teams, including Market Access, Medical Affairs, Advocacy, Marketing, and Site of Care to facilitate and improve patient access to insurance, medications, financial support, resources and more. Responsibilities - Secure written or electronic patient HIPAA for patients in the assigned geography - Develop relationships with patients and caregivers by engaging via phone, text, email, virtual or in person connections - Assess individual needs of the patient and develop an appropriate education and resource plan of action, considering the patient’s family and team of healthcare providers to empower the patient to become their own advocate - Educate the patient on Krystexxa coverage based on their benefits and the steps needed to gain prior authorization to ensure understanding of the process for medication access - Provide information on co-pay assistance programs, national foundations, and free drug programs by sharing information to patients as appropriate and needed - Provide proactive education to prescribers and sites of care upon patient enrollment on coverage for Amgen rare disease therapies, common prior authorization requirements, and coding and billings requirements - Provide access and reimbursement education based on the enrolled patient’s Krystexxa benefits to physician offices and sites of care - Educate the physician office and/or SOC on Krystexxa coverage based on the patient’s benefits and the steps needed to gain prior authorization to ensure understanding of the process for medication access - Investigate access challenges pre and post-infusion to include support for denied claims and claim reviews - Partner with Safety and PV and report AE’s and product complaints through medical information. - Work closely with the Amgen cross functional team including Case Managers, the Site of Care team, market access, matrix partners and external vendors - Adhere to professional standards compliance guidance, policies and procedures, federal, state, and local requirements What we expect of you We are all different, yet we all use our unique contributions to serve patients. The dynamic professional we seek is someone with these qualifications. Basic Qualifications: - Doctorate degree AND 2 years of Sales/ Account Management OR direct patient care experience OR - Master's degree AND 4 years of Sales/ Account Management OR direct patient care experience OR - Bachelor's degree AND 6 years of Sales/Account Management OR direct patient care experience Preferred Qualifications: - Scientific background and ability to learn product and disease information. - Nursing or other clinical background a plus - Access and reimbursement for buy and bill products - Orphan or Rare disease experience. - Familiarity with HIPAA guidelines and FDA requirements. - Familiarity with and Adherence to internal and OIG Compliance guidelines a must - Ability to handle difficult patient cases and resolve hurdles. - Ability to work in team environment and manage communication with case Liaisons and sales reps. - Ability to respond immediately when necessary (within 24 hours) to prevent lapses in treatment. - Strong analytical skills and ability to report on meaningful activity in the region. - Proficient in Microsoft Office. - Professional, proactive demeanor. - Strong interpersonal skills and strategic mindset. - Excellent written and verbal communication skills. - Potential for up to 50% travel, including some overnight and weekend commitments. What you can expect of us As we work to develop treatments that take care of others, we also work to care for your professional and personal growth and well-being. From our competitive benefits to our collaborative culture, we’ll support your journey every step of the way. The expected annual salary range for this role in the U.S. (excluding Puerto Rico) is posted. Actual salary will vary based on several factors including but not limited to, relevant skills, experience, and qualifications. In addition to the base salary, Amgen offers a Total Rewards Plan, based on eligibility, comprising of health and welfare plans for staff and eligible dependents, financial plans with opportunities to save towards retirement or other goals, work/life balance, and career development opportunities that may include: - A comprehensive employee benefits package, including a Retirement and Savings Plan with generous company contributions, group medical, dental and vision coverage, life and disability insurance, and flexible spending accounts - A discretionary annual bonus program, or for field sales representatives, a sales-based incentive plan - Stock-based long-term incentives - Award-winning time-off plans - Flexible work models where possible. Refer to the Work Location Type in the job posting to see if this applies. Apply now and make a lasting impact with the Amgen team. careers.amgen.com In any materials you submit, you may redact or remove age-identifying information such as age, date of birth, or dates of school attendance or graduation. You will not be penalized for redacting or removing this information. Application deadline Amgen does not have an application deadline for this position; we will continue accepting applications until we receive a sufficient number or select a candidate for the position. Sponsorship Sponsorship for this role is not guaranteed. As an organization dedicated to improving the quality of life for people around the world, Amgen fosters an inclusive environment of diverse, ethical, committed and highly accomplished people who respect each other and live the Amgen values to continue advancing science to serve patients. Together, we compete in the fight against serious disease. Amgen is an Equal Opportunity employer and will consider all qualified applicants for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, disability status, or any other basis protected by applicable law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation. .Salary Range 178,336.00 USD - 201,298.00 USD

United States
$178K - $201K / year
Job Closed

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. Job Description Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT ***Highly preferred that candidate resides in the state of Georgia in either Richmond, Chatham, Muscogee, Dekalb, Fulton or surrounding areas. Role will require local travel.*** Position Purpose: Serves as a vital link between members and the healthcare system, focusing on improving health outcomes by identifying and closing care gaps. This role emphasizes community engagement, member education, and collaboration with providers and internal teams to ensure members receive timely, appropriate care and support. - Conduct outreach to members in the community to identify care gaps and connect them with appropriate healthcare services and resources. - Perform home visits or community-based assessments to evaluate member needs and identify social determinants of health that may prevent members from accessing preventive or follow-up care, and facilitate care coordination. - Serve as a member advocate by helping individuals navigate complex healthcare and social service systems. Assist with scheduling appointments, understanding care plans, and accessing benefits or entitlements, ensuring members receive the support needed to close care gaps and maintain continuity of care - Collaborate with providers to share quality performance data (e.g., HEDIS, CAHPS) and support improvement initiatives. - Educate members on preventive care, chronic condition management, and available community resources. - Document member interactions, care gap closures, and referrals in the appropriate systems. - Partner with internal departments (e.g., Quality, Care Management, Provider Relations) to align efforts and improve member outcomes. - Monitor and report on outreach effectiveness and care gap closure metrics. - Maintain compliance with state and federal regulations and organizational policies. - Participate in seasonal campaigns and quality initiatives to improve member engagement and health outcomes. - Serve as a community ambassador, building relationships with local organizations and stakeholders. - Performs other duties as assigned. - Complies with all policies and standards. Education/Experience: Bachelor's Degree Social Work, Public Health, Nursing, or related field; or equivalent experience required 2+ years In community health or healthcare quality required Experience working with health plan members and navigating community resources required Familiarity with Medicaid / Medicare programs and quality measures (e.g., HEDIS) required Strong communication and interpersonal skills Licenses/Certifications: LCSW- License Clinical Social Worker preferred RN - Registered Nurse - State Licensure and/or Compact State Licensure preferred Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

United States
$27 - $49 / hour
Job Closed
OtherRemoteTeam 1,001-5,000

The Billing and Posting Resolution Advocate is responsible for overseeing claims production, billing, follow-up, collections, and compliance with third party payer regulations. This position is responsible for daily oversight and management of process-based revenue cycle functions, including ongoing improvement to key revenue cycle indicators. These indicators include but are not limited to: A/R days, cash collection goals and posting, denials, underpayment and contract management activities related to patient account management. The Billing Manager should have comprehensive knowledge of revenue cycle operations. The position is responsible for personnel development and initiating disciplinary action according to policy. Essential Functions: In addition to working as prescribed in our Performance Factors specific responsibilities of this role include: - Possess complete understanding of the billing/collection process to resolve complex, outstanding claims. - Ensures accounts are billed accurately and timely by providing proactive oversight and direction for billing and collections. - Provides operational oversight for the Billing Coordinator, mentoring them in their responsibilities - Maintains current knowledge of hospital billing systems and government payer systems, including applicable federal/state laws and regulations, as well as all aspects of third-party reimbursement policies and practices - Demonstrates ability to manage, train and motivate employees, as well as a professional attitude in relating to executive management, professionals and third-party insurance carriers. - Organizes and leads efforts to maximize operational efficiency and optimize reimbursement, as well as monitors denials and provides education and reporting to the areas regarding the effect of denials from their areas. - Reviews all statistical reports to monitor trends, determine operational deficiencies and implement corrective action plans as necessary - Pro-active communication/escalation of potential claims/unbilled accounts/issues to the Director - Exhibits excellent leadership and self-direction, good judgement in handling difficult situations and good organizational, time management, interpersonal and conflict resolution skills. - Assures that confidentiality of patient information is maintained without exception - Attends all required meetings and activities, maintaining a professional affiliation to stay abreast of current trends and changes in legislation and industry best practices. - Liaise with facility management and operates as the lead point of contact - Maintain employee time and attendance and scheduling demands - Responsible for accuracy of customer invoices, and creating the invoices monthly - Understanding the contract terms and insuring we stay within those terms - Performs all functions from the Management Expectations List - Performs all other duties assigned Minimum Requirements: Education/Experience/Certification Requirements - High school graduate or GED equivalent - 3 years previous hospital billing experience - Working knowledge of insurance regulations, procedure and diagnosis coding and automated insurance billing - Excellent communication (written and oral) and interpersonal skills - Excellent critical thinking, organizational and time management skills with a strong attention to detail, accuracy and follow through - Must be able to work through issues to resolution Preferred Qualifications: - Associates or Bachelor’s Degree - 2 years Medicare hospital billing experience Why join our team? - Work remotely with a work/life balance approach - Robust benefits offering, including 401(k) - Generous time off allotments - 10 paid holidays annually - Employer-paid short term disability and life insurance - Paid Parental Leave

United States
Job Closed
CVS Health logo

Health Advocate - Outbound Calls, Healthy Outcomes Team - Work From Home

CVS Health

CVS Health is a leading healthcare company operating CVS Specialty, CVS Pharmacy, CVS MinuteClinic, and CVS Caremark. In 2018, CVS combined forces with healthca

Customer Advocate100 days ago

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Is your passion helping others? Are you a dynamic communicator? A team player? Do you thrive in a fast-paced environment? If so, we are looking for you! The Healthy Outcomes Team is a health advocacy team looking for dedicated friendly colleagues to help the Medicare population learn about and complete important health screenings and activities. As a Health Advocate on the Healthy Outcomes Team, you will interact with members telephonically to inspire healthy behaviors. Our goal on each call is to give every member a clear understanding of their benefits for specific screenings and medications. You will talk to providers and members to assist with important health services, medications, and resources to improve Star health outcomes. Your key responsibilities are: - Inbound and outbound calls to members and providers to help getting services like healthcare visits, screenings, vaccinations, or medication refills. - Working through barriers that stand in the way of our members’ good health - Delivering the best member experience through professional empathetic conversations - Provide important education to members to help them make good health decisions that improve their health - Accurately document conversations in the member’s health record Your key abilities are: - High-energy engagement to provide exceptional service - Empathetic, curious, with an enthusiasm for learning - Knowledge retention and recall to answer questions and resolve issues - Desire to understand and meet our members’ needs and escalate issues for resolution - Speed and efficiency to meet business metrics and goals. - Ability to handle pressure and to stay calm and positive in all situations - Ability to work independently, apply critical thinking skills when needed, multitask with ease, and demonstrate professionalism in all interactions. - Ability to absorb and apply new and changing information. - Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment Required Qualifications - Professional communication skills - Strong active listening and interpersonal skills - High computer literacy, including ability to troubleshoot issues - Proficiency with Windows and web-based applications and digital communication tools - Reliable high-speed internet connection (at least 50mbps) and suitable remote workspace - Hard wired connectivity to computer is required (DSL, satellite, and wireless broadband are not permitted) Preferred Qualifications - Bilingual or multilingual candidates heavily preferred. - Experience with HEDIS screening measures - Experience with behavior change - 2+ years’ experience with call center or outreach involving members/consumers - 3+ years’ experience in a healthcare setting - Medical certification (certified nursing assistant, medical assistant, etc.) Education High School diploma or equivalent preferred but not required. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $17.00 - $31.30 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: - Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. - No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. - Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 03/28/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

United States
$17 - $31 / hour
Job Closed