Utilization Management Representative II

Elevance Health•Tampa, FL

3d•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. 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, and candidates must 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; a 10% shift differential applies.

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.
For URAC-accredited areas, strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Availability to work four days Monday through 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, within a reasonable commuting distance of a posting location unless an accommodation is granted.

Nice To Haves

Medical terminology training and experience in the medical or insurance field.
Ability to adapt to evolving technologies.
Versatility in managing multiple responsibilities.
Strong problem-solving, facilitation, and analytical skills.
A master's degree may be required for certain contracts.

Responsibilities

Manage incoming calls and incoming post-service claims work, including triage and opening cases.
Determine contract and benefit eligibility and provide authorizations for inpatient admissions, outpatient precertification, prior authorization, and post-service requests.
Obtain demographic intake information from callers.
Conduct 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 in-house departments.
Conduct the clinical screening process.