Utilization Management Representative II - Benefit Investigation

Utilization Management Representative II – Benefit Investigation Work hours: Monday - Friday, 8:30 – 5pm EST, with flexibility to work 11:30 – 8pm EST during training period of 8-12 weeks. Hybrid/Virtual Work Policy 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. 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 a 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. Benefits We offer a range of market-competitive total rewards that include 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 and financial education resources. Vaccination Requirement The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Equal Employment Opportunity Statement Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, and local laws. Applicants who require accommodation to participate in the job application process may contact View email address on click.appcast.io for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration. #J-18808-Ljbffr Elevance Health