Utilization Management Representative II

Elevance Health•Tampa, FL

5d•Remote

About The Position

The Utilization Management Representative II manages incoming calls and post-service claims work, including triage, case opening, and authorization of sessions. The role determines contract and benefit eligibility and provides authorization for inpatient admissions, outpatient precertification, prior authorization, and post-service requests. The selected candidate must reside in Lake Mary, Tampa, or Miami, Florida. The position is virtual full-time except for required in-person training sessions; candidates must also live within a reasonable commuting distance of the listed locations unless an accommodation is granted as required by law. The schedule requires availability to work four days between Monday and Friday from 12 p.m. to 9 p.m. EST, plus one weekend day per week. The posting notes a 10% shift differential. The role may act as a liaison between Medical Management and internal departments and responds to telephone and written inquiries from clients, providers, and in-house departments.

Requirements

High school diploma or equivalent.
A minimum of 2 years of customer service experience in a healthcare-related setting and medical terminology training, or an equivalent combination of education and experience.
Availability to work four weekdays between Monday and Friday from 12 p.m. to 9 p.m. EST and one weekend day per week.
Must reside in Lake Mary, Tampa, or Miami, Florida, and be within a reasonable commuting distance of the posting location unless an accommodation is granted as required by law.

Nice To Haves

Strong oral, written, and interpersonal communication skills.
Strong problem-solving, facilitation, and analytical skills.
Medical terminology training and experience in the medical or insurance field.
Open-mindedness and adaptability to evolving technologies.
Versatility and ability to manage multiple responsibilities.
A Master's degree may be required for certain contracts.

Responsibilities

Manage incoming calls and incoming post-service claims work.
Triage requests, open cases, and authorize sessions.
Determine contract and benefit eligibility.
Provide authorization for inpatient admission, outpatient precertification, prior authorization, and post-service requests.
Obtain demographic intake information from callers.
Conduct thorough radius searches in Provider Finder and follow up with providers on referrals given.
Refer cases requiring clinical review to a nurse reviewer and handle referrals for specialty care.
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.