Utilization Management Representative II

The Elevance Health Companies, Inc.; San Antonio (TX); Hybrid; USD 42,000 - 64,000; Full time

Job summary

BioPlus Specialty Pharmacy, a member of the Elevance Health family, seeks an Utilization Management Representative II to manage incoming calls, triage cases, and authorize sessions. This role supports clinical decision processes and works with providers to verify benefits and eligibility.

The position emphasizes accurate data collection, coverage determinations, and liaison duties across Medical Management and other departments. A healthcare-focused, customer-service mindset is essential.

Qualifications

• HS diploma or equivalent.
• Minimum 2 years of customer service experience in a healthcare setting with medical terminology training.

Responsibilities

• Manage incoming calls and triage healthcare requests.
• Determine contract and benefit eligibility; authorize inpatient/outpatient services and precertification.
• Obtain demographic information from callers and gather needed documentation.
• Refer cases for clinical review when needed and handle referrals for specialty care.
• Verify benefits/eligibility and coordinate with internal departments.

Skills

Prior authorization

Precertification

Communication

Analytical skills

Education

HS diploma

Job description

Date

Anticipated End Date: 2026-09-21

Position Title

Utilization Management Representative II

Location

This role requires associates to work from the posted locations full-time, enabling consistent face-to-face collaboration, teamwork, and direct engagement. This policy promotes an environment built on in-person interaction, communication, and immediate support. This position will be based at the following location: 4751 Hamilton Wolf Rd, Ste 101, San Antonio - TX. 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 shift, Monday through Friday. Candidate should have availability from 8:00 am to 6:00 pm (CDT). Additional hours, including weekends or holidays, may be required based on operational needs.

About the Role

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

Key Responsibilities

• 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 Experiences

• Knowledge of health plans, including familiarity with prior authorization and precertification process; knowledge of contracts and strong knowledge of managed benefit programs strongly preferred.
• Previous experience of prior -authorization management is strongly preferred.
• Prior experience working in a high-volume environment is preferred.
• 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

Job Level: Non-Management Non-Exempt

Workshift

Workshift: 1st Shift (United States of America)

Job Family

Job Family: CUS > Care Support

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 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.

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.

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 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.