Utilization Management Representative II

Elevance Health (Anthem); Mason (OH); Hybrid; USD 55,000 - 70,000; Full time

Benefits offered by this job

Merit increases

Paid time off

Medical

Dental

Vision

401(k) + match

Stock purchase plan

Life insurance

Wellness programs

Job summary

Elevance Health is seeking an Utilization Management Representative II to handle incoming calls, triage cases, and authorize sessions across inpatient, outpatient, and post-service requests.

You will collect demographic data, verify benefits, and coordinate with nurse reviewers on referrals for specialty care. The role supports hybrid/virtual work with in-person onboarding requirements and cross-functional collaboration.

Qualifications

• Requires high school diploma or equivalent and a minimum of 2 years customer service experience in a healthcare related setting.
• Medial terminology training or background is preferred.
• Strong communication and problem-solving skills required.

Responsibilities

• Manage incoming calls and triage patient inquiries.
• Determine contract and benefit eligibility; authorize inpatient admissions, outpatient precertification, prior authorization, and post-service requests.
• Obtain demographic information from callers.
• Conduct neighborhood radius searches in Provider Finder and follow up with providers on referrals.
• Refer cases requiring clinical review to nurse reviewer; handle referrals for specialty care.
• Process requests and collect information needed for review from providers, using scripts to screen basic and complex requests for precertification and/or prior authorization.
• Verify benefits and/or eligibility information.
• Act as liaison between Medical Management and internal departments as needed.
• Respond to telephone and written inquiries from clients, providers and in-house departments.
• Conduct clinical screening process.

Skills

Customer service

Healthcare terminology

MS Excel

Education

High school diploma or equivalent

Tools

Excel

Job description

Position Title

Utilization Management Representative II

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 Introduction

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.

Role Overview

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

How you will make an impact

• 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; 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.
• 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.

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.

Professional Competencies

For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Certain contracts require a Master's degree.

Job Level

Non-Management Non-Exempt

Job Family

CUS > Care Support

Company Policy

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.

Benefits and Perks

• merit increases
• paid holidays
• Paid Time Off
• 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
• financial education resources

Hybrid Workforce Strategy

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