Utilization Management Representative II - Benefit Investigation
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Key skills for this role
About the Role
Elevance Health is seeking a Utilization Management Representative II to manage incoming calls, triage, open cases, and authorize sessions. Responsibilities include determining benefit eligibility, providing authorization for inpatient/outpatient services, and verifying benefits.
Key Skills for This Role
Responsibilities
- Manage incoming calls, including triage, opening of cases and authorizing sessions
- Determine contract and benefit eligibility; provide authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests
- Obtain intake (demographic) information from caller
- Conduct thorough radius search in Provider Finder and follow up with provider on referrals given
- Refer cases requiring clinical review to a nurse reviewer; handle referrals for specialty care
- Process incoming requests, collect information needed for review from providers, utilizing scripts to screen basic and complex requests for precertification and/or prior authorization
- Verify benefits and/or eligibility information
- May act as liaison between Medical Management and internal departments
- Respond to telephone and written inquiries from clients, providers and in house departments
- Conduct clinical screening process
Requirements
- HS diploma or equivalent
- Minimum of 2 years customer service experience in healthcare related setting and medical terminology training
- Certain contracts require a Master's degree
- Experience working in health insurance or with a managed care organization preferred
- Prior knowledge in infusion pharmacy or benefit investigation strongly preferred
- Ability to self start, be coachable and flexible strongly preferred
- Prior experience with navigating multiple systems, partners, and internal & external customers strongly preferred
- Experience working with the CPR+ platform or CareTend platform is a plus
Full Job Posting
Overview
- Virtual role enabling associates to work virtually full time except for required in person training sessions.
- BioPlus Specialty Pharmacy is a member of Elevance Health family.
- Work hours: Monday Friday, 8:30 – 5pm EST, with flexibility to work 11:30 – 8pm EST during training period of 8 12 weeks.
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 Qualifications
- 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.
- Certain contracts require a Master's degree.
Preferred Skills, Capabilities And Experiences
- Experience working in health insurance or with a managed care organization is preferred.
- Prior knowledge in infusion pharmacy or benefit investigation is strongly preferred.
- Ability to self start, be coachable and flexible is strongly preferred.
- Prior experience with navigating multiple systems, partners, and internal & external customers is strongly preferred.
- Experience working with the CPR+ platform or CareTend platform is a plus.
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