Utilization Management Representative II

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.

The Utilization Management Representative II responsible for managing incoming calls, including triage, opening of cases and authorizing sessions, and supporting timely prior authorization decisions (including specialty infusion therapies).

How you will make an impact:

• Managing incoming calls or incoming post services claims work (including specialty infusion prior authorization requests for high-cost therapies such as biologics and complex IV medications).
• Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests; submits, tracks, and follows up on authorizations as needed.
• 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, and reviews supporting documentation (clinical notes/labs when applicable) to meet payer-specific criteria.
• Verifies benefits and/or eligibility information, coordinating with commercial insurance, Medicare/Medicaid, and PBMs as needed.
• May act as liaison between Medical Management and internal departments.
• Responds to telephone and written inquiries from clients, providers and in-house departments; communicates authorization status updates to providers/clinical staff, and supports denial follow-up by coordinating additional medical necessity information when needed.
• Conducts clinical screening process and documents authorization details (e.g., approval dates and reference numbers) in the system.

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.
• Experience with HCPCS (J-codes), ICD-10 coding, and clinical criteria guidelines (e.g., InterQual or MCG) is strongly preferred.
• Experience with Electronic Medical Records (EMR) systems (e.g., Epic, WebRx, CPR+) and prior authorization portals (e.g., CoverMyMeds, Availity) is preferred.
• Understanding of major medical insurance, PBMs, buy-and-bill models, Medicare Parts B and D, and Medicaid guidelines is preferred.

Job Level: Non-Management Non-Exempt

Workshift: 1st Shift (United States of America)

Job Family: CUS > Care Support