Utilization Management Rep II/Clinical Liaison

About the role

This role enables associates to work virtually full-time, except for 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. Alternate locations may be considered if candidates reside within a commuting distance from an office. 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 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 You Will Make An Impact

Primary duties may include, but are not limited to:

• Managing incoming calls or incoming post services claims work.
• Determining contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests.
• Obtaining intake (demographic) information from caller.
• Conducting a thorough radius search in Provider Finder and follows up with provider on referrals given.
• Referring cases requiring clinical review to a nurse reviewer; and handles referrals for specialty care.
• Processing incoming requests, collection of information needed for review from providers, utilizing scripts to screen basic and complex requests for precertification and/or prior authorization.
• Verifying benefits and/or eligibility information.
• May act as liaison between Medical Management and internal departments.
• Responding to telephone and written inquiries from clients, providers and in-house departments.
• Conducting 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.

Preferred Skills, Capabilities And Experiences

• 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.

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.