Remote Utilization Management Specialist II

Elevance Health; Mason (OH); Hybrid; USD 42,000 - 60,000; Full time

Job summary

Elevance Health's BioPlus Specialty Pharmacy is hiring for an Utilization Management Representative II. The role involves handling high volumes of calls, triage, opening cases, and authorizing sessions across multiple locations including Mason, OH.

You will verify benefits, determine eligibility, and facilitate approvals for inpatient and outpatient services. The position emphasizes strong communication, clinical screening, and collaboration with nurse reviewers and internal departments.

Qualifications

• HS diploma or equivalent with a minimum of 2 years customer service experience in healthcare setting or equivalent.
• Medical terminology training or equivalent background.

Responsibilities

• Manage incoming calls and triage; open cases and authorize sessions.
• Determine contract and benefit eligibility; provide inpatient/outpatient approvals and prior authorization.
• Obtain intake information from callers and verify demographics.
• Conduct radius search in Provider Finder and follow up with providers on referrals.
• Refer cases for clinical review to a nurse reviewer and arrange referrals for specialty care.
• Process requests with required information for review; screen for precertification and preauthorization.
• Verify benefits/eligibility information; act as liaison between Medical Management and other departments.
• Respond to inquiries from clients, providers and internal teams.
• Conduct clinical screening as part of the review process.

Skills

Customer service

Interpersonal communication

Excel

Education

HS Diploma or equivalent

Job description

Elevance Health's BioPlus Specialty Pharmacy is hiring for an Utilization Management Representative II. The role involves handling high volumes of calls, triage, opening cases, and authorizing sessions across multiple locations including Mason, OH.

You will verify benefits, determine eligibility, and facilitate approvals for inpatient and outpatient services. The position emphasizes strong communication, clinical screening, and collaboration with nurse reviewers and internal departments.