Position Title: Utilization Management Rep I (PHL) Shift: Job Description: Responsible for coordinating cases for precertification and prior authorization review. Primary duties may include, but are not limited: Manages 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. Requires High school diploma/GED; 1 year of customer service or call-center experience in healthcare related setting; proficient analytical, written and oral communication skills; or any combination of education and experience, which would provide an equivalent background. Medical terminology training and experience in medical or insurance field 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. Care meets innovation Our name translates to “providing full and complete care” and reinforces our commitment to putting people first in all that we do. We specialize in contact center operations (call and chat) and clinical nurse operations for Elevance Health. With four offices in prime locations across the Philippines—two in Manila and two in Iloilo—we boast a talent pool of more than 9,000 associates all working together to improve healthcare operations. We use the right balance of care, technology, data, and expertise to streamline experiences and create value for our clients, people, and community. We also recognize the value that our associates bring, and that is why we are committed to providing the same through competitive compensation and comprehensive benefits such as rewards and recognition programs, health and medical insurance, and best-in-class amenities to keep associates and their families healthy and secure. At Carelon Global Solutions Philippines, we care for those who provide care. Join us today. We celebrate and leverage our associates' limitless skills, talents, unique perspectives, and experiences. By respecting our people's culture and background, we foster a collaborative and purpose-driven workplace where everyone can grow and thrive in their careers. If you are a recent senior high school or college graduate looking to get a head start in your career, we are the right team for you. Our people-first approach supports professional development by providing associates with the right tools and training that align with their aspirations.

Utilization Management Rep I (PHL).

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