Utilization Management Representative II

Utilization Management Representative II

Location: The selected candidate for this position must reside in Lake Mary, Tampa or Miami Florida.

Hours: Must be available to work 4 days between Monday - Friday from 12 pm - 9 pm EST + one weekend day per week (to include a 10% shift differential).

Virtual: 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.

The Utilization Management Representative II is responsible for managing incoming calls, including triage, opening of cases and authorizing sessions.

How will you 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 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.

Preferred Skills, Capabilities and Qualifications:

• 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.
• Medical terminology training and experience in medical or insurance field preferred.
• Open-minded and adaptable to evolving technologies
• Versatile and able to manage multiple responsibilities
• Background in healthcare with training in medical terminology
• Experience in the medical or insurance field
• Excellent problem-solving, facilitation, and analytical skills

Job Level: Non-Management Non-Exempt

Workshift: 2nd Shift (United States of America)

Job Family: CUS > Care Support