Utilization Management Representative II

Position Title

Utilization Management Representative II

Utilization Management Representative II

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. The position will be based on Mason - OH, Durham- NC and Tampa
-FL.

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.

This position will work an 8-hour from shift 8:00 am - 5:00 pm (EST) Monday to Friday. Additional hours may be necessary based on company needs.

Bio Plus Specialty Pharmacy is a proud member of the Elevance Health family of companies . Bio Plus offer consumers and providers an unparalleled level of service that's easy and focused on whole health. Through our distinct clinical expertise, digital capabilities, and broad access to specialty medications across a wide range of conditions, we deliver an elevated experience, affordability, and personalized support throughout the consumer's treatment journey.

The Utilization Management Representative II responsible for managing incoming calls, including triage, opening of cases and authorizing sessions.

• 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.
• Obtains intake (demographic) information from caller.
• Conducts a thorough radius search in Provider Finder and follows up with provider on referrals given.
• Refers cases requiring clinical review to a nurse reviewer; and handles referrals for specialty care.
• Processes incoming requests, collection of information needed for review from providers, utilizing scripts to screen basic and complex requests for precertification and/or prior authorization.
• Verifies benefits and/or eligibility information.
• May act as liaison between Medical Management and internal departments.
• Responds to telephone and written inquiries from clients, providers and in-house departments.
• Conducts clinical screening process.

Requires HS diploma or equivalent and a minimum of 2 years customer service experience in healthcare related setting and medical terminology training; or any combination of education and experience which would provide an equivalent background.

Intermediate experience with excel is 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. Certain contracts require a Master's degree.

Non-Management Non-Exempt

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.

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