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Insurance Utilization Reviewer Jobs in Georgia (NOW HIRING)

Phoebe Putney Health System

... Utilization review duties in Care Management. Timely communication of clinical information and updates will be provided to the insurance companies as requested or required by contract or federal and ...

Ourhrconnect

Provides support and review of medical claims and utilization practices. Description Why should you ... We are the largest insurance company in South Carolina ... and much more. We are one of the nation ...

New

Ourhrconnect

Provides support and review of medical claims and utilization practices. Description Why should you ... We are the largest insurance company in South Carolina ... and much more. We are one of the nation ...

New

Bestica Healthcare

RN Case Manager

Atlanta, GA · On-site

Utilize Milliman Guidelines Utilization Review: * Admission Criteria Appeals and Denials ... HIPAA guidelines (Health Insurance Portability and Accountability Act) * ICD 10 Coding * NCQA ...

Elevance Health

Utilization Management Rep I

Atlanta, GA · On-site

$36K - $41K/yr

Refers cases requiring clinical review to a Nurse reviewer. * Responsible for the identification ... Medical terminology training and experience in medical or insurance field preferred. * For URAC ...

genex

Telephonic Nurse Case Manager

Atlanta, GA · On-site

Interface with external agencies/representatives relative to the utilization review process including, but not limited to, Third-Party Payers, Insurance Companies and Providers. Perform Utilization ...

genex

Telephonic Nurse Case Manager

Atlanta, GA · On-site

Interface with external agencies/representatives relative to the utilization review process including, but not limited to, Third-Party Payers, Insurance Companies and Providers. Perform Utilization ...

Genex

Telephonic Nurse Case Manager

Atlanta, GA · On-site

... utilization review process including, but not limited to, Third-Party Payers, Insurance Companies and Providers. • Perform Utilization Review activities prospectively, concurrently or ...

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Insurance Utilization Reviewer information

What are the key skills and qualifications needed to thrive as an Insurance Utilization Reviewer, and why are they important?

To thrive as an Insurance Utilization Reviewer, you need a solid understanding of medical terminology, healthcare regulations, and insurance processes, usually supported by a clinical background or relevant certification. Familiarity with utilization review software, electronic health records (EHRs), and coding systems like ICD-10 and CPT is often required. Strong analytical thinking, attention to detail, and effective communication skills help reviewers assess medical necessity and coordinate with healthcare providers. These skills ensure accurate, efficient case evaluations and compliance with policies, which are crucial for optimizing patient care and managing healthcare costs.

What is the difference between Insurance Utilization Reviewer vs Insurance Claims Processor?

AspectInsurance Utilization ReviewerInsurance Claims Processor
Primary RoleReview medical necessity and appropriateness of services for insurance coverageProcess and review insurance claims for payment and accuracy
Required CredentialsOften requires healthcare or insurance certifications, such as RHIT or CPCTypically requires claims processing or insurance certifications, like CPC or CPC-H
Work EnvironmentHealthcare settings, insurance companies, or third-party administratorsInsurance companies, healthcare providers, or claims processing centers
Industry UsageCommonly employed in health insurance and managed careWidely used across health, auto, and property insurance sectors

The main difference is that Insurance Utilization Reviewers focus on evaluating the medical necessity of services, while Insurance Claims Processors handle the administrative processing of claims. Both roles require insurance-related certifications and are integral to the insurance industry, but they serve distinct functions in the claims and coverage review process.

What are some common challenges faced by Insurance Utilization Reviewers, and how can they be addressed?

One of the primary challenges Insurance Utilization Reviewers face is balancing the need to adhere to strict insurance guidelines while advocating for appropriate patient care. Reviewers often handle high caseloads and must make timely decisions based on complex medical records, which requires strong attention to detail and up-to-date knowledge of coverage policies. Effective communication with healthcare providers and insurance representatives is also crucial to resolve discrepancies and ensure approvals. Staying organized, continuously updating clinical knowledge, and leveraging support from the utilization review team can help manage these challenges successfully.

What are Insurance Utilization Reviewers?

Insurance Utilization Reviewers are professionals who evaluate healthcare services to determine if they are medically necessary and covered by insurance policies. They review patient records, treatment plans, and insurance guidelines to ensure that the care provided aligns with established criteria and standards. Their work helps control healthcare costs, prevent unnecessary treatments, and ensure patients receive appropriate care. Utilization reviewers often communicate with healthcare providers and insurance companies to support or deny coverage decisions.
What are popular job titles related to Insurance Utilization Reviewer jobs in Georgia? For Insurance Utilization Reviewer jobs in Georgia, the most frequently searched job titles are:
What job categories do people searching Insurance Utilization Reviewer jobs in Georgia look for? The top searched job categories for Insurance Utilization Reviewer jobs in Georgia are:
What cities in Georgia are hiring for Insurance Utilization Reviewer jobs? Cities in Georgia with the most Insurance Utilization Reviewer job openings:
Insurance Utilization Reviewer jobs near you
Utilization Management Representative I

Utilization Management Representative I

Elevance Health

Columbus, GA

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 6 days ago

Elevance Health rating

7.7

Company rating: 7.7 out of 10

Based on 348 frontline employees who took The Breakroom Quiz

183rd of 281 rated insurance

Job description

Anticipated End Date:

2026-07-17

Position Title:

Utilization Management Representative I

Job Description:

Utilization Management Representative I

Location: This role enables associates to work virtually full-time, except for 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 is responsible for coordinating cases for precertification and prior authorization review.

Hours: Training is conducted from 7:00 AM to 3:30 PM Mountain Time, with standard shift hours from 8:30 AM to 5:30 PM Mountain Time. Please adjust for your time zone. Candidates will be required to work rotating weekends and select holidays, and must be flexible and available to work overtime. Weekend shift hours may vary.

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.

  • Associates in this role are expected to have the ability to multi-task, including handling calls, texts, facsimiles, and electronic queues, while simultaneously taking notes and speaking to customers.

  • Additional expectations to include but not limited to: Proficient in maintaining focus during extended periods of sitting and handling multiple tasks in a fast-paced, high-pressure environment; strong verbal and written communication skills, both with virtual and in-person interactions; attentive to details, critical thinker, and a problem-solver; demonstrates empathy and persistence to resolve caller issues completely; comfort and proficiency with digital tools and platforms to enhance productivity and minimize manual efforts.

  • Associates in this role will have a structured work schedule with occasional overtime or flexibility based on business needs, including the ability to work from the office as necessary.

  • Performs other duties as assigned.

Minimum Requirements:

  • Requires HS diploma or GED and a 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:

  • Inbound call center experience strongly preferred.

  • Medical terminology training and experience in medical or insurance field strongly 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.

Job Level:

Non-Management Non-Exempt

Workshift:

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 should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact. 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.


NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words - the job is posted until 3/13, not through 3/13.

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About Elevance Health

Sourced by ZipRecruiter

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?

Industry

Health care and social assistance

Company size

10,000+ Employees

Headquarters location

Indianapolis, IN, US

Year founded

2004

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