Utilization Management Representative II

Elevance Health•San Antonio, TX

1d•Onsite

About The Position

The Utilization Management Representative II is responsible for managing incoming calls, including triage, opening of cases and authorizing sessions. Primary duties may include, but are not limited to: 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.

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.

Nice To Haves

Knowledge of health plans, including familiarity with prior authorization and precertification process; knowledge of contracts and strong knowledge of managed benefit programs strongly preferred.
Previous experience of prior -authorization management is strongly preferred.
Prior experience working in a high-volume environment is preferred.
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.

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.