Utilization Management Representative II

Elevance Health; Tampa (FL); A distancia; USD 25.000 - 33.000; Jornada completa

Descripción de la vacante

Elevance Health is seeking a detail-oriented Utilization Management Representative II to manage inbound calls, determine eligibility, and authorize care. The role supports virtual work with required in-person training sessions and may require commuting within a reasonable distance to posting locations in Florida.

You will collect patient demographics, perform clinical screening, and liaise with medical management and other departments to ensure timely and accurate authorizations and referrals.

Formación

• Minimum 2 years customer service experience in a healthcare-related setting.
• Medical terminology training or equivalent background desired.

Responsabilidades

• Handle incoming calls and triage patient inquiries.
• Determine contract and benefit eligibility for authorizations.
• Obtain intake information from callers and verify demographics.
• Conduct radius searches in Provider Finder and follow up with providers.
• Refer cases requiring clinical review to a nurse reviewer.
• Process requests for precertification and/or prior authorization with scripts.

Conocimientos

Customer service

Healthcare terminology

Phone handling

Communication

Problem-solving

Detail-oriented

Educación

HS diploma or equivalent

Medical terminology training

Descripción del empleo

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