Utilization Management Representative II

Elevance Health (Anthem); San Antonio (TX); On-site; USD 42,000 - 65,000; Full time

Job summary

Elevance Health in San Antonio, TX is seeking an Utilization Management Representative II to support eligibility determinations, pre-authorizations, and clinical referrals. This onsite role requires full-time coverage with a Monday–Friday 8:00 am–6:00 pm CST schedule, and may include additional hours based on needs.

You'll handle incoming calls and post-service claims, verify benefits, collect demographics, and coordinate with nurse reviewers and care teams to ensure timely authorizations and

Qualifications

• Requires HS diploma or equivalent and at least 2 years of healthcare customer service experience.
• Medical terminology training or equivalent background.
• Experience with health plans, prior authorization, and precertification preferred.
• Experience in a high-volume environment preferred.

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 information from caller.
• Conducts a 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.

Skills

Customer service

Medical terminology

Health plans knowledge

Prior authorization

High-volume environment

Education

HS Diploma

Medical terminology training

Job description

Position Title: 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.

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.

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 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

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 financia