Utilization Management Representative II

We need to output HTML fragment with sections: headings

for sections like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Only include sections if posting has real specific content. We must not repeat job title as heading. No Job ID etc. Remove boilerplate, navigation, legal, EEO, etc. Also remove application instructions. Keep substantive info. Let's parse the posting. Location paragraph: describes virtual full-time except required in-person training, locations: Mason - OH, Durham- NC and Tampa -FL. Also note about commuting distance. This is location info; maybe we can include under "About the role" or "Location". There's no explicit heading for location but we could include under "About the role". The instruction: Use

for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). So we can create sections as needed. Schedule: "This position will work an 8-hour from shift 8:00 am - 5:00 pm (EST) Monday to Friday. Additional hours may be necessary based on company needs." That's schedule content. Pay: Not mentioned. So we should NOT include Pay section. Benefits: There's a paragraph about total rewards: "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 financial education resources, to name a few." That's benefits content. So include Benefits section. About the role: Could include description of role, location, mission, etc. The posting includes: "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. The Utilization Management Representative II responsible for managing incoming calls, including triage, opening of cases and authorizing sessions, and supporting timely prior authorization decisions (including specialty infusion therapies)." Also location paragraph. Also "How You Will Make An Impact" bullet list of duties. That's responsibilities. We need to separate Responsibilities and maybe Requirements/Qualifications/Skills. 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: list of items. Thus we can have sections: About the role (maybe includes location and company description), Responsibilities (the "How You Will Make An Impact" list), Requirements (minimum qualifications), Qualifications (maybe combine with Requirements? but we can separate: Requirements = minimum qualifications, Qualifications = preferred skills? The instruction list includes Requirements, Qualifications, Skills. Could treat Requirements as minimum qualifications, Qualifications as preferred skills/experience, Skills as maybe specific technical skills? But we can combine. Better: Use sections: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Schedule. We need to ensure we don't create sections with filler. All have content. Let's extract content. About the role: Should include location flexibility, company description, role purpose. We'll write a paragraph summarizing: location (virtual full-time with required in-person training, based in Mason-OH, Durham-NC, Tampa-FL, must be within commuting distance), company (BioPlus Specialty Pharmacy, part of Elevance Health), mission (provide service focused on whole health, etc.), role (Utilization Management Representative II manages incoming calls, triage, prior auth, etc.). We'll keep it concise but preserve all substantive info. Must not invent or summarize away detail. We need to preserve all substantive information; we can paraphrase but must keep details. Let's try to keep the key facts. Location: "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. The position will be based on Mason - OH, Durham- NC and Tampa -FL. 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." Company description: "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." Role purpose: "The Utilization Management Representative II responsible for managing incoming calls, including triage, opening of cases and authorizing sessions, and supporting timely prior authorization decisions (including specialty infusion therapies)." We can combine into About the role. Responsibilities: The "How You Will Make An Impact" paragraph is a long sentence with many duties separated by periods. We need to turn into list items

• . Let's extract each duty. Original: "Managing incoming calls or incoming post services claims work (including specialty infusion prior authorization requests for high-cost therapies such as biologics and complex IV medications).Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests; submits, tracks, and follows up on authorizations as needed. 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, and reviews supporting documentation (clinical notes/labs when applicable) to meet payer-specific criteria.Verifies benefits and/or eligibility information, coordinating with commercial insurance, Medicare/Medicaid, and PBMs as needed.May act as liaison between Medical Management and internal departments.Responds to telephone and written inquiries from clients, providers and in-house departments; communicates authorization status updates to providers/clinical staff, and supports denial follow-up by coordinating additional medical necessity information when needed.Conducts clinical screening process and documents authorization details (e.g., approval dates and reference numbers) in the system." We need to split into sensible list items. Each sentence separated by period. Let's list: - Managing incoming calls or incoming post services claims work (including specialty infusion prior authorization requests for high-cost therapies such as biologics and complex IV medications). - Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests; submits, tracks, and follows up on authorizations as needed. - 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, and reviews supporting documentation (clinical notes/labs when applicable) to meet payer-specific criteria. - Verifies benefits and/or eligibility information, coordinating with commercial insurance, Medicare/Medicaid, and PBMs as needed. - May act as liaison between Medical Management and internal departments. - Responds to telephone and written inquiries from clients, providers and in-house departments; communicates authorization status updates to providers/clinical staff, and supports denial follow-up by coordinating additional medical necessity information when needed. - Conducts clinical screening process and documents authorization details (e.g., approval dates and reference numbers) in the system. That seems comprehensive. Requirements (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." We can put as a paragraph or list? It's a single statement; we can use

  . Qualifications (preferred skills): list of preferred skills. Preferred Skills, Capabilities, And Experiences: "Intermediate experience with excel is strongly preferred.Experience with HCPCS (J-codes), ICD-10 coding, and clinical criteria guidelines (e.g., InterQual or MCG) is strongly preferred. Experience with Electronic Medical Records (EMR) systems (e.g., Epic, WebRx, CPR+) and prior authorization portals (e.g., CoverMyMeds, Availity) is preferred. Understanding of major medical insurance, PBMs, buy-and-bill models, Medicare Parts B and D, and Medicaid guidelines is preferred." We can split into list items. Skills: maybe we could separate technical skills like Excel, EMR, prior auth portals, coding. But we already have Qualifications covering preferred skills. The instruction list includes Skills as separate; we could put specific technical skills there, but we risk duplication. However we can still include Skills section with items like "Intermediate Excel proficiency", "HCPCS (J-codes) coding", "ICD-10 coding", "Clinical criteria guidelines (InterQual or MCG)", "EMR systems (Epic, WebRx, CPR+)", "Prior authorization portals (CoverMyMeds, Availity)". That would be a subset of Qualifications. But we risk repeating content. The instruction says "Prefer a few substantive sections over many thin ones." So maybe we combine Qualifications and Skills into one section called "Qualifications & Skills". But they gave examples of headings; we can choose to include only those with real content. We could have sections: About the role, Responsibilities, Requirements, Qualifications, Benefits, Schedule. That's six sections. Qualifications can include both minimum and preferred? But we already have Requirements for minimum. Qualifications for preferred. That seems fine. Skills maybe not needed separately. We'll omit Skills section. Benefits: we have paragraph. Schedule: we have paragraph. Now we must ensure we don't include boilerplate like EEO, vaccination policy, etc. Remove all that. Also remove "Please be advised that Elevance Health only accepts resumes for compensation from agencies..." etc. That's boilerplate/application instructions; remove. Remove "Who We Are", "How We Work", etc. Those are boilerplate; remove. Now produce HTML fragment. We'll wrap sections in maybe not required. Just output headings and content. Structure:

  About the role

  ... (combined location, company description, role purpose)

  Responsibilities

  • ...
  ...

  Requirements

  HS diploma or equivalent and a minimum of 2 years customer service experience in a healthcare-related setting with medical terminology training; or any combination of education and experience that provides an equivalent background.

  Qualifications

  • Intermediate experience with Excel (strongly preferred)
  • Experience with HCPCS (J-codes), ICD-10 coding, and clinical criteria guidelines (e.g., InterQual or MCG) (strongly preferred)
  • Experience with Electronic Medical Records (EMR) systems (e.g., Epic, WebRx, CPR+) and prior authorization portals (e.g., CoverMyMeds, Availity) (preferred)
  • Understanding of major medical insurance, PBMs, buy-and-bill models, Medicare Parts B and D, and Medicaid guidelines (preferred)