Utilization Management Representative II

Position Title Utilization Management Representative II Job Description Utilization Management Representative II Location 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. Schedule 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. BioPlus Specialty Pharmacy Introduction BioPlus Specialty Pharmacy is a proud member of the Elevance Health family of companies . BioPlus 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. Role Overview The Utilization Management Representative II 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. Minimum Qualifications 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. Preferred Skills, Capabilities, and Experiences Intermediate experience with excel is strongly preferred. Professional Competencies 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. Job Level Non-Management Non-Exempt Job Family CUS > Care Support Company Policy 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. Who We Are 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. How We Work 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. Benefits and Perks merit increases paid holidays Paid Time Off incentive bonus programs (unless covered by a collective bargaining agreement) medical dental vision short and long term disability benefits 401(k) +match stock purchase plan life insurance wellness programs financial education resources Hybrid Workforce Strategy Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements #J-18808-Ljbffr