Utilization Management Representative II - Benefit Investigation

Utilization Management Representative II - Benefit Investigation

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. Alternate locations may be considered if candidates reside within a commuting distance from an office.

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.

Work hours: Monday - Friday, 8:30 – 5pm EST, with flexibility to work 11:30 – 8pm EST during training period of 8-12 weeks.

The Utilization Management Representative II – Benefit Investigation 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.

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.
• Certain contracts require a Master's degree.

Preferred Skills, Capabilities and Experiences:

• Experience working in health insurance or with a managed care organization is preferred.
• Prior knowledge in infusion pharmacy or benefit investigation is strongly preferred.
• Ability to self-start, be coachable and flexible is strongly preferred.
• Prior experience with navigating multiple systems, partners, and internal & external customers is strongly preferred.
• Experience working with the CPR+ platform or CareTend platform is a plus.
• Candidates in alternate locations are welcome to apply provided they reside within commuting distance of a Pulse Point office location.

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.

Job Level: Non-Management Non-Exempt

Workshift: Job Family: CUS > Care Support