Utilization Management Representative II

Elevance Health; Miami (FL); Hybrid; USD 42,000 - 64,000; Full time

Job summary

Elevance Health is seeking an Utilization Management Representative II in Florida. The role involves handling incoming calls, triaging cases, authorizing inpatient and outpatient services, and gathering demographic information.

The position supports a hybrid/virtual work model with required in-person training sessions. The role requires a high school diploma or equivalent and at least two years of healthcare customer service experience, with strong communication and analytical skills.

Qualifications

• Minimum of 2 years of customer service experience in a healthcare-related setting.
• Medical terminology training or coursework.
• Strong oral and written communication skills.
• Ability to handle multiple tasks and prioritize in a fast-paced environment.

Responsibilities

• Manage incoming calls and triage and open cases.
• Authorize inpatient admission, outpatient precertification, prior authorization, and post-service requests.
• Obtain intake information from callers and verify benefits/eligibility.
• Conduct radius searches in Provider Finder and coordinate referrals.
• Refer cases for clinical review to a nurse reviewer as needed.
• Screen requests for precertification and/or prior authorization with scripts.
• Serve as liaison between Medical Management and internal departments.
• Respond to inquiries from clients and providers in a timely manner.
• Perform clinical screening as part of the intake process.

Skills

Customer service

Healthcare terminology

Communication skills

Problem solving

Education

HS diploma or equivalent

Master’s degree (preferred in some contracts)

Tools

Medical terminology training

Job description

Location: The selected candidate for this position must reside in Lake Mary, Tampa or Miami Florida.

Hours: Must be available to work 4 days between Monday - Friday from 12 pm - 9 pm EST + one weekend day per week (to include a 10% shift differential).

Virtual: This role enables associates to work virtually full-time, with the exception of 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.

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.

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

How Will You 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 Requirements

• 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 Qualifications

• 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.
• Medical terminology training and experience in medical or insurance field preferred.
• Open-minded and adaptable to evolving technologies.
• Versatile and able to manage multiple responsibilities.
• Background in healthcare with training in medical terminology.
• Experience in the medical or insurance field.
• Excellent problem-solving, facilitation, and analytical skills.

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.