Utilization Management Representative II

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

Job summary

Elevance Health’s BioPlus Specialty Pharmacy seeks an Utilization Management Representative II in San Antonio, TX. This full-time, onsite role handles incoming calls, triage, and case openings, while authorizing sessions and confirming benefit eligibility within a structured health plan environment.

Responsibilities include collecting caller demographics, routing cases for clinical review, and coordinating with nursing staff and internal departments.

Qualifications

• Requires HS diploma or equivalent and a minimum of 2 years customer service experience in healthcare related setting and medical terminology training.

Responsibilities

• Handle incoming calls and triage cases.
• Determine eligibility and authorize inpatient admission, outpatient precertification, prior authorization, and post-service requests.
• Obtain intake (demographic) information from caller.
• Refer cases requiring clinical review to a nurse reviewer; handle referrals for specialty care.
• Process requests and collect information for review from providers using scripts to screen preliminary and complex requests.
• Verify benefits and/or eligibility information.
• Coordinate with Medical Management and internal departments as needed.

Skills

Healthcare customer service

Medical terminology

High-volume environment

Oral and written communication

Education

HS diploma or equivalent

Tools

Provider Finder system

Job description

Anticipated End Date: 2026-11-09 Position Title: Utilization Management Representative II Job Description: Utilization Management Representative II Location: 4751 Hamilton Wolf Rd, Ste 101, San Antonio-TX. Onsite: 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. 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 (CST). Additional hours, including weekends or holidays, may be required based on operational needs.

Be Part of an Extraordinary Team 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.

Primary duties may include, but are not limited to:

• 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: Non-Management Non-Exempt Workshift: Job Family: CUS > Care Support

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 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.

NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words — the job is posted until 3/13, not through 3/13.

Company History

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.

Join our Talent Community and stay connected with company news, information, and future job opportunities. Fueled by our bold purpose to improve the health of humanity, we are transforming from a traditional health benefits organization into a lifetime trusted health partner.Our nearly 100,000 associates serve approximately 100M+ people, at every stage of health. We address a full range of needs with an integrated whole health approach, powered by industry-leading capabilities and a digital platform for health.

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/Disability/Veterans.

Please visit the Contract Worker Community Page. Elevance Health is an Equal Opportunity Employer/Disability/Veterans.