Utilization Management Representative II

Elevance Health•Tampa, FL

3d•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 enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Candidates must reside in Lake Mary, Tampa or Miami Florida and be available to work 4 days between Monday - Friday from 12 pm - 9 pm EST + one weekend day per week (to include a 10% shift differential).

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

Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Certain contracts require a Master's degree.
Medical terminology training and experience in medical or insurance field preferred.
Open-minded and adaptable to evolving technologies
Versatile and able to manage multiple responsibilities
Background in healthcare with training in medical terminology
Experience in the medical or insurance field
Excellent problem-solving, facilitation, and analytical skills.

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.