[Hiring] Utilization Management Representative II @Elevance Health

Role Description

The Utilization Management Representative II is responsible for managing incoming calls, including triage, opening of cases and authorizing sessions.

• 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; handles referrals for specialty care.
• Processes incoming requests, collecting 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.

Qualifications

• 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.

Requirements

• For URAC accredited areas, the following professional competencies apply:
• 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.

Benefits

• Market-competitive total rewards including merit increases, paid holidays, Paid Time Off, and incentive bonus programs.
• Medical, dental, vision, short and long term disability benefits.
• 401(k) + match, stock purchase plan, life insurance.
• Wellness programs and financial education resources.