Utilization Management Representative II - Benefit Investigation

Elevance Health•Durham, NC

1d•Hybrid

About The Position

The Utilization Management Representative II - Benefit Investigation role at BioPlus Specialty Pharmacy, a member of the Elevance Health family of companies, is a virtual full-time position. While primarily virtual, it requires attendance at in-person training sessions. Candidates must reside within a commuting distance from an office, as those outside this range will not be considered unless an accommodation is granted. BioPlus aims to provide unparalleled, easy, and whole-health focused service to consumers and providers through clinical expertise, digital capabilities, and broad access to specialty medications. This role is responsible for managing incoming calls, including triage, opening cases, and authorizing sessions.

Requirements

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.

Nice To Haves

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.
Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills (for URAC accredited areas).

Responsibilities

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.