Utilization Management Representative II

Location: The selected candidate for this position must reside in Lake Mary, Tampa or Miami Florida. Hours: Must be available to work 4 days between Monday - Friday from 12 pm - 9 pm EST + one weekend day per week (to include a 10% shift differential). Virtual: This role enables associates to work virtually full-time, with the exception of 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. 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. The Utilization Management Representative II is responsible for managing incoming calls, including triage, opening of cases and authorizing sessions. How Will You 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 Requirements 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 Qualifications 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.Medical terminology training and experience in medical or insurance field preferred. Open-minded and adaptable to evolving technologiesVersatile and able to manage multiple responsibilitiesBackground in healthcare with training in medical terminologyExperience in the medical or insurance fieldExcellent problem-solving, facilitation, and analytical skills