Utilization Management Rep II

Utilization Management Representative II

Location:
You must in reside in the state of Wisconsin, within a commutable distance to our Waukesha, WI office located at N17W24222 Riverwood Drive, Suite 300, Waukesha, WI 53188 .

Virtual: 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.

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 accommodation is granted as required by law.

The Utilization Management Representative II will be 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 /li
• 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.

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

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.

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.

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…