Remote Utilization Management Specialist II

Elevance Health; Durham (NC); Hybrid; USD 55,000 - 75,000; Full time

Job summary

Elevance Health is seeking an Utilization Management Representative II to manage inbound calls, determine eligibility, and authorize services within a hybrid/virtual work model. The role supports prior authorization decisions for complex therapies and coordinates with providers and internal teams.

The successful candidate will have healthcare customer service experience, familiarity with medical terminology, and knowledge of insurance guidelines, including PA processes and EMR systems.

Qualifications

• HS diploma or equivalent and a minimum of 2 years customer service experience in healthcare related setting and medical terminology training.
• Experience with insurance processes, prior authorization and medical terminology is preferred.
• Familiarity with EMR systems and PA portals is preferred.

Responsibilities

• Handle inbound calls and triage as part of prior authorization and post-service requests.
• Determine eligibility and authorize inpatient/outpatient services per payer criteria.
• Collect demographics and provider information to support timely decisions.
• Coordinate with nurses for clinical reviews and referrals to specialty care.
• Document authorization details in the system and follow up on denials.

Skills

Customer service

Medical terminology

Insurance knowledge

Clinical knowledge

Education

High School Diploma

Tools

Epic

WebRx

CPR+

CoverMyMeds

Availity

MS Excel

Job description

Elevance Health is seeking an Utilization Management Representative II to manage inbound calls, determine eligibility, and authorize services within a hybrid/virtual work model. The role supports prior authorization decisions for complex therapies and coordinates with providers and internal teams.

The successful candidate will have healthcare customer service experience, familiarity with medical terminology, and knowledge of insurance guidelines, including PA processes and EMR systems.