Utilization Management Representative II

Elevance Health • San Antonio, TX

13d • Onsite

About The Position

The Utilization Management Representative II at BioPlus Specialty Pharmacy, part of Elevance Health, manages incoming calls and post-service claims work, including triage, case opening, and authorization sessions. The role determines contract and benefit eligibility and provides authorization for inpatient admissions, outpatient precertification, prior authorization, and post-service requests. It is based onsite at 4751 Hamilton Wolf Rd, Ste 101, San Antonio, Texas. Associates work an eight-hour shift Monday through Friday and must be available between 8:00 a.m. and 6:00 p.m. CST. Additional hours, including weekends or holidays, may be required based on operational needs.

Requirements

• High school diploma or equivalent.
• 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.
• Strong oral, written, and interpersonal communication skills for associates in URAC-accredited areas.
• Problem-solving, facilitation, and analytical skills for associates in URAC-accredited areas.

Nice To Haves

• Knowledge of health plans, including familiarity with prior authorization and precertification processes.
• Knowledge of contracts and strong knowledge of managed benefit programs.
• Previous prior-authorization management experience.
• Experience working in a high-volume environment.

Responsibilities

• Manage incoming calls and incoming post-service claims work.
• 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 radius searches in Provider Finder and follow up with providers regarding referrals.
• 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 internal departments.
• Conduct the clinical screening process.

Benefits

• Merit increases
• Paid holidays
• Paid time off
• Incentive bonus programs, unless covered by a collective bargaining agreement
• Medical benefits
• Dental benefits
• Vision benefits
• Short- and long-term disability benefits
• 401(k) with matching
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED