Utilization Management Representative II

The Elevance Health Companies, Inc.; Cincinnati (OH); Hybrid; USD 52,000 - 78,000; Full time

Job summary

BioPlus Specialty Pharmacy, part of Elevance Health, seeks a Utilization Management Representative II to manage authorizations, eligibility and prior authorization workflows in a flexible hybrid setting.

The role involves handling inbound calls, verifying benefits, coordinating with providers, and supporting clinical reviews, with in-person onboarding and training as required.

Qualifications

• HS diploma or equivalent with a minimum of 2 years of healthcare customer service experience.
• Medical terminology training; familiarity with healthcare terminology and payer processes.

Responsibilities

• Handle incoming calls and post-service claims work; including prior authorization for high-cost therapies.
• Determine contract and benefit eligibility; provide authorization for inpatient/outpatient services and post-service requests.

Skills

Customer service experience

Medical terminology training

Education

HS diploma or equivalent

Tools

Epic

WebRx

CPR+

CoverMyMeds

Availity

Job description

Utilization Management Representative II

Anticipated End Date: 2026-09-22

Location

This role enables associates to work virtually full-time, except for 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. Alternate locations may be considered if candidates reside within a commuting distance from an office. The position will be based on Mason - OH, Durham- NC and Tampa -FL. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Schedule

This position will work an 8-hour from shift 8:00 am - 5:00 pm (EST) Monday to Friday. Additional hours may be necessary based on company needs.

Company Overview

BioPlus Specialty Pharmacy is a proud member of the Elevance Health family of companies. BioPlus offer consumers and providers an unparalleled level of service that’s easy and focused on whole health. Through our distinct clinical expertise, digital capabilities, and broad access to specialty medications across a wide range of conditions, we deliver an elevated experience, affordability, and personalized support throughout the consumer’s treatment journey.

How you will make an impact

• Managing incoming calls or incoming post services claims work (including specialty infusion prior authorization requests for high-cost therapies such as biologics and complex IV medications).
• Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests; submits, tracks, and follows up on authorizations as needed.
• 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, and reviews supporting documentation (clinical notes/labs when applicable) to meet payer-specific criteria.
• Verifies benefits and/or eligibility information, coordinating with commercial insurance, Medicare/Medicaid, and PBMs as needed.
• May act as liaison between Medical Management and internal departments.
• Responds to telephone and written inquiries from clients, providers and in-house departments; communicates authorization status updates to providers/clinical staff, and supports denial follow-up by coordinating additional medical necessity information when needed.
• Conducts clinical screening process and documents authorization details (e.g., approval dates and reference numbers) in the system.

Minimum 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.

Preferred Skills, Capabilities, and Experiences

• Intermediate experience with excel is strongly preferred.
• Experience with HCPCS (J-codes), ICD-10 coding, and clinical criteria guidelines (e.g., InterQual or MCG) is strongly preferred.
• Experience with Electronic Medical Records (EMR) systems (e.g., Epic, WebRx, CPR+) and prior authorization portals (e.g., CoverMyMeds, Availity) is preferred.
• Understanding of major medical insurance, PBMs, buy-and-bill models, Medicare Parts B and D, and Medicaid guidelines is preferred.

Job Level

Non-Management Non-Exempt

Workshift

1st Shift (United States of America)

Job Family

CUS > Care Support

About Elevance Health

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Equal Employment Opportunity

Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.

Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.

We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Applicants who require accommodation to participate in the job application process should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.

Elevance Health is an Equal Opportunity Employer/Disability/Veterans.