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Utilization Management Rep Jobs in California (NOW HIRING)

Loma Linda University Health

Case Manager

Loma Linda, CA

$20.50 - $26.50/hr

Maintains a solid working knowledge of specialized case and utilization management methodologies ... Represents nursing as an empowered profession and readily embraces new knowledge, innovations and ...

Loma Linda University Health

Case Manager

Murrieta, CA

$20.25 - $26/hr

Maintains a solid working knowledge of specialized case and utilization management methodologies ... Represents nursing as an empowered profession and readily embraces new knowledge, innovations and ...

Loma Linda University Health

Case Manager*

Murrieta, CA

$20.25 - $26/hr

Maintains a solid working knowledge of specialized case and utilization management methodologies ... Represents nursing as an empowered profession and readily embraces new knowledge, innovations and ...

Loma Linda University Health

Case Manager*

Murrieta, CA · On-site

$68.03 - $91.49/hr

Maintains a solid working knowledge of specialized case and utilization management methodologies ... Represents nursing as an empowered profession and readily embraces new knowledge, innovations and ...

Loma Linda University Health

Case Manager*

Murrieta, CA

$20.50 - $26.25/hr

Maintains a solid working knowledge of specialized case and utilization management methodologies ... Represents nursing as an empowered profession and readily embraces new knowledge, innovations and ...

Loma Linda University Health

Case Manager

Murrieta, CA · On-site

$59.18 - $79.60/hr

Maintains a solid working knowledge of specialized case and utilization management methodologies ... Represents nursing as an empowered profession and readily embraces new knowledge, innovations and ...

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Utilization Management Rep information

What are the key skills and qualifications needed to thrive as a Utilization Management Representative, and why are they important?

To thrive as a Utilization Management Representative, you need a solid understanding of healthcare policies, medical terminology, and insurance processes, typically supported by a background in healthcare administration or a related field. Familiarity with utilization review software, electronic medical records (EMR), and claims management systems is typically required. Strong attention to detail, effective communication, and customer service skills help you excel when coordinating between providers, members, and insurance teams. These competencies ensure accurate case review, regulatory compliance, and positive patient outcomes in a complex healthcare environment.

How does a Utilization Management Rep collaborate with healthcare providers and internal teams to ensure appropriate patient care?

A Utilization Management Rep frequently interacts with healthcare providers, such as physicians and nurses, to gather clinical information and clarify treatment plans. They also work closely with internal medical directors, case managers, and claims teams to review authorization requests and determine medical necessity based on established guidelines. Effective communication and teamwork are key, as the role requires balancing patient needs, provider requests, and payer policies to facilitate timely, appropriate care decisions. This collaboration ensures that patients receive necessary services while helping to control healthcare costs.

What is the difference between Utilization Management Rep vs Utilization Review Coordinator?

AspectUtilization Management RepUtilization Review Coordinator
CertificationsCPUR, RHIT, or similarCPUR, RHIT, or similar
Work EnvironmentHealthcare insurance companies, hospitalsHealthcare insurance companies, hospitals
Job FocusReviewing and authorizing healthcare servicesCoordinating and managing review processes

Both roles involve reviewing healthcare services, often requiring similar certifications. The Utilization Management Rep primarily assesses and authorizes services, while the Utilization Review Coordinator manages the review process and coordinates between providers and payers. They often work in similar environments within the healthcare insurance industry, with overlapping responsibilities but different focus areas.

What is a Utilization Management Rep?

A Utilization Management Representative, often called a UM Rep, is a professional who reviews medical service requests to ensure that treatments and procedures are medically necessary and covered by a patient's insurance plan. They work with healthcare providers, insurance companies, and patients to review clinical information, authorize care, and sometimes suggest alternative treatments based on policy guidelines. UM Reps play a key role in managing healthcare costs while maintaining quality care by adhering to established criteria and regulations.
What are popular job titles related to Utilization Management Rep jobs in California? For Utilization Management Rep jobs in California, the most frequently searched job titles are:
What job categories do people searching Utilization Management Rep jobs in California look for? The top searched job categories for Utilization Management Rep jobs in California are:
Utilization Management Rep jobs near you
PROVIDER AND CLIENT SERVICES REPRESENTATIVE

PROVIDER AND CLIENT SERVICES REPRESENTATIVE

North East Medical Services

Burlingame, CA • On-site

$32.08 - $36.15/hr

Other

Medical, Dental, Vision, Retirement

Posted 8 days ago

Job description

The MSO Provider and Client Services Representative (PCSR) is responsible for providing general administrative support to the MSO Department and works in conjunction with the MSO Value Based Care Programs team.
This position is responsible for handling inquiries from providers, vendors, and clients in relation to NEMS MSO operations such as claims processing, utilization management, and value-based care improvement activities. The PCSR works on projects/assignments of limited complexity in a supporting role.
The MSO Network Provider and Client Services Representative is required to have excellent ability to communicate effectively with a variety of professionals, including physicians, administrators, other healthcare providers, and services agencies.
ESSENTIAL JOB FUNCTIONS:
  • Responsible to provide primary support to MSO Utilization Management, and Claims main phone line, general mailbox, voicemails, faxes, and other administrative tasks
  • Responsible to research and understand basic authorizations, claims, provider appeals, benefit coverage issues raised by physician practices and/or health plan partners, coordinate follow up activities for resolution.
  • Responsible for coordinating investigation activities for member grievances; track progress and report results to contracted Health Plan(s) within required timeframe.
  • Assist the Value Based Care Programs team with outreach phone calls and other patient care improvement activities.
  • Thoroughly and efficiently respond to all emails and/or voicemails that require any action in a timely manner.
  • Complete other administrative and clerical tasks as assigned.
  • Performs other job duties as required by manager/supervisor.

QUALIFICATIONS:
  • BA/BS Degree is preferred.
  • One-year experience working in healthcare setting is preferred.
  • Must have excellent communication skills (verbal and written), ability to communicate effectively with a variety of professionals, including physicians and other healthcare providers, business administrators and other healthcare services agencies.
  • Must be PC literate - Strong Excel, Word, Power point, and Outlook skills.
  • Detail-oriented and organized with the ability to interpret policy and make decisions.
  • Good organization and problem-solving skills.
  • Ability to self-manage and work with multiple departments within the organization and external clients.
  • Knowledge of managed care and Medicare/Medi-Cal program is strongly preferred.

LANGUAGE:
  • Must be able to fluently speak, read and write English.
  • Fluent in Chinese (Cantonese and/or Mandarin) preferred
  • Fluency in other languages is an asset.

STATUS:
  • This is an FLSA Non-exempt position.
  • This is not an OSHA high-risk position.
  • This is a full-time position.

NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).

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