Utilization Management II

Elevance Health•Durham, NC

1d•Remote

About The Position

The Utilization Management Representative II manages incoming calls and post-service claims work, including triage, opening cases, and authorizing sessions. The role determines contract and benefit eligibility and provides authorization for inpatient admissions, outpatient precertification, prior authorization, and post-service requests. It obtains demographic information from callers, verifies benefits and eligibility, and conducts clinical screening. The representative collects information needed for review from providers, uses scripts to screen basic and complex requests, refers cases requiring clinical review to a nurse reviewer, and handles specialty-care referrals. The role also conducts provider searches in Provider Finder and follows up with providers on referrals, responds to telephone and written inquiries, and may act as a liaison between Medical Management and internal departments. The position is primarily virtual, with required in-person training sessions. Candidates must be within a reasonable commuting distance of the listed locations unless an accommodation is granted. The schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m. Eastern, with additional hours potentially needed based on company needs.

Requirements

High school diploma or equivalent, and at least 2 years of customer service experience in a healthcare-related setting and medical terminology training; or an equivalent combination of education and experience.
For URAC-accredited areas, strong oral, written, and interpersonal communication, problem-solving, facilitation, and analytical skills are expected.

Nice To Haves

Intermediate Excel experience is strongly preferred.
Certain contracts require a master's degree.

Responsibilities

Manage incoming calls or incoming post-service claims work.
Triage calls, open cases, and authorize sessions.
Determine contract and benefit eligibility and provide authorization for inpatient admissions, outpatient precertification, prior authorization, and post-service requests.
Obtain demographic intake information from callers.
Conduct provider searches in Provider Finder and follow up with providers about referrals.
Refer cases requiring clinical review to a nurse reviewer and handle specialty-care referrals.
Process incoming requests and collect information needed for review from providers.
Use scripts to screen basic and complex precertification and prior authorization requests.
Verify benefits and eligibility information.
Act as a liaison between Medical Management and internal departments, as needed.
Respond to telephone and written inquiries from clients, providers, and in-house departments.
Conduct the clinical screening process.