Utilization Management Representative 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

Utilization Management Representative II

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.

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.

Utilization Management Representative II responsible for managing incoming calls, including triage, opening of cases and authorizing sessions, and supporting timely prior authorization decisions (including specialty infusion therapies).

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.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. 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.

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. Applicants who require accommodation to participate in the job application process should submit the 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.