manager utilization management

Physicians Data Trust

<div><ul><li>Primary Purpose</li></ul>
To provide high-level customer service to PDTs&rsquo; clients with accuracy.<ul><li>
Principal Duties and Responsibilities - *Goals on Performance Review</li></ul><ul><li>
Answer calls from members, providers, and health plans regarding specific claim issues. Route and redirect calls as necessary.</li><li><ul><li>Return calls from the UM voicemail box within 24 hours</li><li>Perform timely follow-up on calls requiring research and call back within 24 hours.</li></ul></li><li>
Accurately interpret DOFRs &ndash; Division of Financial Responsibility documents to determine where specific health care services are rendered.</li><li>
Verify eligibility &amp; benefits for each submitted physician referral by contacting health plans for pertinent information.</li><li>
Work with contracting personnel to ensure the utilization of appropriate providers.</li><li><ul><li>Provide requested referral and network information to providers/staff promptly within 24 hours.</li></ul></li><li>
Use MedMC to log incoming calls and their resolution.</li><li>
Complete other projects as assigned by the supervisor</li><li>
Job Specifications (KSAs):<ul><li>
Requires the ability to speak, read, write, and understand English and other general educational skills, as is generally obtained by completing high school or a GED.</li><li>
Knowledge of the health or managed care industry is generally obtained through 1-2 years of work experience.</li><li>
Excellent communication skills with a focus on superior telephone etiquette.</li><li>
1-2 years of customer service experience required.</li></ul></li></ul>
 IV Position Performance Criteria<ul><li>
Ability to organize and maintain multiple sets of information and data.</li><li>
Consistently produces accurate and timely work as it relates to departmental goals.</li><li>
Demonstrates high reliability through consistent punctuality and attendance.</li><li>
Competently performs position requirements with minimal supervision and direction, including taking initiative and assuming responsibility for follow-through.</li><li>
Uses sound judgment regarding time management and prioritization of work to balance multiple tasks and meet required timeframes for all administrative activities as required.</li><li>
Demonstrates excellent interpersonal skills as discerned through observation and team project successes.</li><li>
Accurately interprets and applies departmental policies and procedures using sound judgment.</li><li>
Communicates professionally and respectfully with peers, superiors, subordinates, and clients.</li><li>
Provides constructive feedback on assigned work projects.</li><li>
Demonstrates overall professionalism in attitude, demeanor, and personal appearance.</li></ul></div>

Utilization Management Customer Service

Elevance Health

<div>Job ID:JP00046432
Anticipated Start Date: 05/13/2026
Please note this is the target date and is subject to change. BCForward will send official notice ahead of a confirmed start date.
Elevance Health is a health company dedicated to improving lives and communities &ndash; 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.
Responsible for coordinating cases for precertification and prior authorization review.
Primary duties may include, but are not limited to:<ul><li>
Managing incoming calls or incoming post services claims work.
</li><li>Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests.</li><li>
Refers cases requiring clinical review to a Nurse reviewer.
</li><li>Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.</li><li>
Responds to telephone and written inquiries from clients, providers and in-house departments.
</li><li>Conducts clinical screening process.
</li><li>Authorizes initial set of sessions to provider.
</li><li>Checks benefits for facility based treatment.
</li><li>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.</li></ul>
Requirements:<ul><li>
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.
</li><li>Associates will need to review service details and enter the authorization in our system and electronically send a confirmation letter to the provider. Associates will need to review our fax queues and pend a line in our UM system.</li><li>
Medical terminology training and experience in medical or insurance field preferred.
</li><li>Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.</li></ul>
Job Type: Contract Opportunity only
Additional Details:<ul><li>
100% remote.
</li><li>Monday - Friday 8 AM-5 PM EST. - NO OVERTIME / NO WEEKEND</li></ul> 
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, contractors 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. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location. 
About BCForward:
Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward's 6,000 consultants support more than 225 clients globally. 
BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work. 
BCForward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability. 
To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process. 
This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.
<div>Pay Rate Range
13.12 - 23.8 USD hourly
</div><div>Additional Notes
The pay range is the range BCForward in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations.
</div><div>Benefits Information
BCForward offers all eligible employees a comprehensive benefits package including, but not limited to major medical, HSA, dental, vision, employer-provided group life, voluntary life insurance, short-term disability, long-term disability, and 401k.
The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. This does not encompass additional non-standard compensation (e.g., benefits, paid time off, per diem, etc.).</div></div>

Utilization Management Rep I (contract)

<div>Job ID:JP00046432
Anticipated Start Date: 05/13/2026
Please note this is the target date and is subject to change. BCForward will send official notice ahead of a confirmed start date.
Elevance Health is a health company dedicated to improving lives and communities &ndash; 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.
Responsible for coordinating cases for precertification and prior authorization review.
Primary duties may include, but are not limited to:<ul><li>
Managing incoming calls or incoming post services claims work.
</li><li>Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests.</li><li>
Refers cases requiring clinical review to a Nurse reviewer.
</li><li>Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.</li><li>
Responds to telephone and written inquiries from clients, providers and in-house departments.
</li><li>Conducts clinical screening process.
</li><li>Authorizes initial set of sessions to provider.
</li><li>Checks benefits for facility based treatment.
</li><li>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.</li></ul>
Requirements:<ul><li>
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.
</li><li>Associates will need to review service details and enter the authorization in our system and electronically send a confirmation letter to the provider. Associates will need to review our fax queues and pend a line in our UM system.</li><li>
Medical terminology training and experience in medical or insurance field preferred.
</li><li>Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.</li></ul>
Job Type: Contract Opportunity only
Additional Details:<ul><li>
100% remote.
</li><li>Monday - Friday 8 AM-5 PM EST. - NO OVERTIME / NO WEEKEND</li></ul>
.Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, contractors 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. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location. 
About BCForward:
Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward's 6,000 consultants support more than 225 clients globally. 
BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work. 
BCForward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability. 
To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process. 
This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.
<div>Pay Rate Range
13.12 - 23.8 USD hourly
</div><div>Additional Notes
The pay range is the range BCForward in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations.
</div><div>Benefits Information
CForward offers all eligible employees a comprehensive benefits package including, but not limited to major medical, HSA, dental, vision, employer-provided group life, voluntary life insurance, short-term disability, long-term disability, and 401k.
The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. This does not encompass additional non-standard compensation (e.g., benefits, paid time off, per diem, etc.).</div></div>

<div>Job ID:JP00046432
Anticipated Start Date: 05/13/2026
Please note this is the target date and is subject to change. BCForward will send official notice ahead of a confirmed start date.
Elevance Health is a health company dedicated to improving lives and communities &ndash; 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.
Responsible for coordinating cases for precertification and prior authorization review.
Primary duties may include, but are not limited to:<ul><li>
Managing incoming calls or incoming post services claims work.
</li><li>Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests.</li><li>
Refers cases requiring clinical review to a Nurse reviewer.
</li><li>Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.</li><li>
Responds to telephone and written inquiries from clients, providers and in-house departments.
</li><li>Conducts clinical screening process.
</li><li>Authorizes initial set of sessions to provider.
</li><li>Checks benefits for facility based treatment.
</li><li>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.</li></ul>
Requirements:<ul><li>
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.
</li><li>Associates will need to review service details and enter the authorization in our system and electronically send a confirmation letter to the provider. Associates will need to review our fax queues and pend a line in our UM system.</li><li>
Medical terminology training and experience in medical or insurance field preferred.
</li><li>Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.</li></ul>
Job Type: Contract Opportunity only
Additional Details:<ul><li>
100% remote.
</li><li>Monday - Friday 8 AM-5 PM EST. - NO OVERTIME / NO WEEKEND</li></ul>
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, contractors 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. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
About BCForward:
Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward's 6,000 consultants support more than 225 clients globally.
BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work.
BCForward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability.
To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process.
This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration. employed
<div>Benefits Information
BCForward offers all eligible employees a comprehensive benefits package including, but not limited to major medical, HSA, dental, vision, employer-provided group life, voluntary life insurance, short-term disability, long-term disability, and 401k.
The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. This does not encompass additional non-standard compensation (e.g., benefits, paid time off, per diem, etc.).</div></div>

<div><h2 class="jobSectionHeader">Description</h2>
Job ID:JP00046432 
Anticipated Start Date: 05/13/2026
Please note this is the target date and is subject to change. BCForward will send official notice ahead of a confirmed start date. 
Elevance Health is a health company dedicated to improving lives and communities &ndash; 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. 
Responsible for coordinating cases for precertification and prior authorization review. 
Primary duties may include, but are not limited to:<ul><li>
Managing incoming calls or incoming post services claims work.</li><li>
Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests.</li><li>
Refers cases requiring clinical review to a Nurse reviewer.</li><li>
Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.</li><li>
Responds to telephone and written inquiries from clients, providers and in-house departments.</li><li>
Conducts clinical screening process.</li><li>
Authorizes initial set of sessions to provider.</li><li>
Checks benefits for facility based treatment.</li><li>
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.</li></ul>
Requirements:<ul><li>
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.</li><li>
Associates will need to review service details and enter the authorization in our system and electronically send a confirmation letter to the provider. Associates will need to review our fax queues and pend a line in our UM system.</li><li>
Medical terminology training and experience in medical or insurance field preferred.</li><li>
Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.</li></ul> 
Job Type: Contract Opportunity only 
Additional Details:<ul><li>
100% remote.</li><li>
Monday - Friday 8 AM-5 PM EST. - NO OVERTIME / NO WEEKEND</li></ul> 
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, contractors 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. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location. 
About BCForward:
Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward's 6,000 consultants support more than 225 clients globally. 
BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work. 
BCForward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability. 
To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process. 
This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.
<div>Pay Rate Range
13.12 - 23.8 USD hourly
</div><div>Additional Notes
The pay range is the range BCForward in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations.
</div><div>Benefits Information
BCForward offers all eligible employees a comprehensive benefits package including, but not limited to major medical, HSA, dental, vision, employer-provided group life, voluntary life insurance, short-term disability, long-term disability, and 401k.
The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. This does not encompass additional non-standard compensation (e.g., benefits, paid time off, per diem, etc.).</div></div>

Spartanburg Regional Healthcare System

<div>Job Requirements 
 
Position Summary 
Under the supervision of the Manager, the Case Manager (CM) has knowledge and skill in the areas of discharge planning, transitions of care, utilization management (UM), medical necessity, and patient status determination. The CM facilitates effective processes based on the regulatory and reimbursement requirements of various commercial and governmental payers. The CM assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. They provide cost-effective services while maintaining quality care through collaboration with health care providers to coordinate the transition of patient care across the continuum, intervening as necessary to remove barriers to timely and efficient care delivery and reimbursement. The CM performing utilization management (UM) provides the critical function of obtaining certification and approval of the patient&rsquo;s hospital stay as required by the payer. 
Minimum Requirements 
Education
<ul><li>Graduate of an accredited school of nursing, Bachelor&rsquo;s Degree (other than nursing) with an ADN or an accredited school of Social Work (MSW)</li></ul>
Experience
<ul><li>1-3 years healthcare experience or 1-3 years Case Management experience (Care Coordination, Transitions of Care or Utilization Management)</li></ul>
License/Registration/Certifications
<ul><li>Current R.N. licensure in the state of SC or Current Social Work licensure in the state of SC</li></ul> 
Preferred Requirements 
Preferred Education
<ul><li>BSN, MSW</li></ul>
Preferred Experience
<ul><li>3-5 years</li></ul>
Preferred License/Registration/Certifications
<ul><li>RN, LMSW</li></ul> 
Core Job Responsibilities 
<ul><li>
Complies with established policies and procedures</li><li>
Complies with regulatory requirements of utilization review and discharge planning</li><li>
Responsible for assessment and reassessment of patients&rsquo; physical, social, emotional and financial needs.</li><li>
Develops a comprehensive patient centered discharge plan, incorporating the patient goal into the discharge plan</li><li>
Communicates with the patient/family/care giver and interdisciplinary patient care team to facilitate patient care, development of a comprehensive patient centered discharge plan and utilization review functions</li><li>
Negotiates timely decisions to expedite the discharge plan and ensure seamless transitions across the continuum of care</li><li>
Documents clearly and concisely all contacts and information of the patient&rsquo;s case management</li></ul>
process in the medical record<ul><li>
Responsible for the core functions of the Utilization Management Plan</li><li>
Performs initial and subsequent utilization reviews utilizing criteria.</li><li>
With utilization review, obtains certification on admissions and continued certification by providing clinical information to the payer or to review companies designated by the patient&rsquo;s payer. Monitor and secures final certification up to and after patient discharge until resolved. Assists with management of incoming faxed communications</li><li>
With utilization review, assists with initial denial, peer to peer information, status determination and/or appeal process and communicates necessary information to the physician advisor, CM manager, denials team manager and/or QIO as required</li><li>
Uses communication tools to ensure that information is collected, reviewed, escalated if needed and disseminated appropriately for all commercial, managed care and government plans.</li><li>
Communicates updated insurance information to the centralized referral center if insurance information provided is not accurate</li><li>
Performs timely data entry of information when results are received including covered, denied and avoidable days.</li><li>
Complies with delivery of regulatory notices - Important Message, Medicare Outpatient Observation Notice, Detailed Notice of Discharge and Hospital Issued Notices of Non-Coverage.</li><li>
Plans effectively in order to meet patient needs, manage length of stay and promote efficient utilization of resources.</li><li>
Provides cost-effective services through resource management and facilitating throughput while maintaining quality care and meeting customer service needs by collaborating with healthcare providers to coordinate care delivery</li><li>
Provides patient/family/caregiver with quality data-based information on post-acute providers to facilitate referrals to meet the care transition needs of the patient</li><li>
Utilizes a secure electronic platform to communicate with post-acute providers and payers</li><li>
Completes required education and ongoing competencies as assigned</li><li>
Updates job knowledge by participating in educational opportunities; reading professional publications; maintaining personal networks; participating in professional organizations</li><li>
Other duties as assigned</li></ul></div>

Case Manager

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