Utilization Management Representative II
About The Position
Utilization Management Representative II Location : This role enables associates to work virtually full-time, with the exception of 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 an accommodation is granted as required by law. Hours : 8:30 AM to 5:00 PM Pacific The Utilization Management Representative II is responsible for managing incoming calls, including triage, opening of cases and authorizing sessions. 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. 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.
Requirements
- 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.
Nice To Haves
- 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.
Responsibilities
- 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.
Benefits
- In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
