Utilization Management Representative II

Elevance Health•Mason, OH

4d•Remote

About The Position

The Utilization Management Representative II is responsible for managing incoming calls, including triage, opening of cases, and authorizing sessions. This role involves determining contract and benefit eligibility, obtaining intake information, conducting provider searches, and referring cases requiring clinical review to a nurse reviewer. The representative will process incoming requests, collect necessary information from providers, utilize scripts for screening, and verify benefits and/or eligibility. They may also act as a liaison between Medical Management and internal departments, and respond to inquiries from clients, providers, and internal departments. This position is based in Mason - OH, Durham- NC and Tampa -FL, and enables associates to work virtually full-time, with the exception of required in-person training sessions. Alternate locations may be considered if candidates reside within a commuting distance from an office. Candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Requirements

HS diploma or equivalent
A minimum of 2 years customer service experience in a healthcare-related setting
Medical terminology training
Any combination of education and experience which would provide an equivalent background.

Nice To Haves

Intermediate experience with excel is strongly preferred.
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.