Utilization Management Representative II

Location & Schedule

This role enables associates to work virtually full‑time, except for required in‑person training sessions, providing maximum flexibility and autonomy. The position is based in Mason, OH; Durham, NC; and Tampa, FL. Alternate locations may be considered for candidates who reside within a reasonable commuting distance from an office. Candidates not within commuting distance will not be considered unless an accommodation is granted as required by law.

The standard schedule is an 8‑hour shift from 8:00 am – 5:00 pm EST, Monday through Friday. Additional hours may be required based on company needs.

About the Role

BioPlus Specialty Pharmacy, a member of the Elevance Health family, delivers an elevated experience, affordability, and personalized support throughout the consumer’s treatment journey. The Utilization Management Representative II is responsible for managing incoming calls, triaging cases, opening cases, and authorizing sessions.

Responsibilities

• Manage incoming calls and post‑service claims work.
• Determine contract and benefit eligibility; provide authorizations for inpatient admission, outpatient precertification, prior authorization, and post‑service requests.
• Obtain intake (demographic) information from callers.
• Conduct a thorough radius search in Provider Finder and follow up with providers on referrals.
• Refer cases requiring clinical review to a nurse reviewer and handle referrals for specialty care.
• Process incoming requests, collect necessary information from providers, and use scripts to screen basic and complex requests for precertification and/or prior authorization.
• Verify benefits and eligibility information.
• Act as liaison between Medical Management and internal departments as needed.
• Respond to telephone and written inquiries from clients, providers, and in‑house departments.
• Conduct clinical screening processes.

Minimum Qualifications

• High school diploma or equivalent.
• At least 2 years of customer service experience in a healthcare‑related setting.
• Medical terminology training, or an equivalent combination of education and experience.

Preferred Skills and Experience

• Intermediate experience with Microsoft Excel.
• Strong oral, written, and interpersonal communication skills.
• Problem‑solving, facilitation, and analytical abilities.
• For URAC‑accredited areas, the professional competencies listed above are expected.
• Certain contracts may require a Master’s degree.

Benefits

• Merit increases and incentive bonus programs (unless covered by a collective bargaining agreement).
• Paid holidays and Paid Time Off.
• Medical, dental, and vision insurance.
• Short‑ and long‑term disability coverage.
• 401(k) plan with employer match.
• Stock purchase plan.
• Life insurance.
• Wellness programs and financial education resources.
• Hybrid workforce strategy – required onsite presence at least once per week unless the role is designated primarily virtual.
• COVID‑19 and Influenza vaccination requirements for patient/member‑facing roles.

About Elevance Health

Elevance Health is a Fortune 25 health company dedicated to improving lives and communities while simplifying healthcare. The organization fosters a culture that supports personal and professional growth, guided by core values and behaviors that drive business outcomes and shared success for consumers, associates, and communities.