Utilization Management Representative II (Virtual in Ohio)

Elevance Health; Seven Hills (OH); Remote; USD 40,000 - 55,000; Full time

Job summary

A leading health insurance provider is seeking a Utilization Management Representative II for a virtual role based in Ohio. The position involves managing incoming calls, authorizing sessions, and determining eligibility for benefits. Candidates should have a high school diploma or equivalent along with customer service experience in a healthcare setting. Strong communication and analytical skills are preferred, with a focus on attention to detail.

Qualifications

• Minimum 2 years customer service experience in healthcare.
• Training in medical terminology is required.

Responsibilities

• Manage incoming calls and authorizing sessions.
• Determine contract and benefit eligibility.
• Conduct clinical screening process.

Skills

Customer service experience

Medical terminology

Strong communication skills

Problem-solving skills

Attention to detail

Education

High school diploma or GED

Job description

Utilization Management Representative II (Virtual in Ohio)

Schedule: Monday-Friday 8am-5pm Eastern Time

Must be located in the state of Ohio

This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy.

The MyCare Ohio health plan is to deliver high‐quality, trauma informed, culturally competent, person‐centered coordination for all members that addresses physical health, behavioral health, long term services and supports, and psychosocial needs.

Responsibilities:

• 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.

Requirements:

• Requires high school diploma or GED 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:

• Experience with LTSS support or waivers strongly preferred.
• Health plan knowledge (prior authorizations experience) strongly preferred.
• Flexibility and strong attention to detail 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 preferred.

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.