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Elevance Health Utilization Management Rep II in San Juan, Puerto Rico

Utilization Management Rep II + Location: National +50 Miles away from nearest PulsePoint, National +50 Miles away from nearest PulsePoint + Job Family: CUS > Care Support + Type: Full time + Date Posted:Jun 15, 2022 + Req #: PS74757 Description As a Utilization Management Representative, you will be responsible for managing incoming calls, including triage, opening of cases, and authorizing sessions. The hours for this position are Monday - Friday, 8:00 am - 5:00 pm PST. How you will make an impact: + Manage incoming calls or post services claims work + Determine contract and benefit eligibility + Provide authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests + Refer cases requiring clinical review to a Nurse reviewer + Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate + Respond to telephone and written inquiries from clients, providers, and in-house departments + Conduct clinical screening process + Authorize initial set of sessions to provider + Checks benefits for facility-based treatment + Develop and maintain positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner. + Obtain intake (demographic) information from caller + Conduct a thorough radius search in Provider Finder and follow up with provider on referrals given + Refers cases requiring clinical review to a nurse reviewer, handle referrals for specialty care + Process incoming requests, collection of information needed for review from providers, utilizing scripts to screen basic and complex requests for precertification and/or prior authorization + May act as liaison between Medical Management and internal departments + Responsible for providing technical guidance to UM Reps who handle correspondence and assist callers with issues concerning contract and benefit eligibility for requested continuing pre-certification and prior authorization of inpatient and outpatient services outside of initial authorized set. + Assisting management by identifying areas of improvement and expressing a willingness to take on new projects as assigned. + Handling escalated and unresolved calls from less experienced team members. + Ensuring UM Reps are directed to the appropriate resources to resolve issues. + Ability to understand and explain specific workflow, processes, departmental priorities and guidelines. + May assist in new hire training to act as eventual proxy for Ops Expert. + Exemplifies behaviors embodied in the 5 Core Values. Minimum Requirements This position can be filled at Utilization Management Representative I or II level. The hiring manager will determine the level, based on the candidate’s experience and background. + UMR I - HS diploma or GED, Minimum of 1 year of customer service or call-center experience, any combination of education and experience which would provide an equivalent background. + UMR II - 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. + UMR III - HS diploma or GED and a minimum of 3 years of experience in customer service experience in healthcare related setting; or any combination of education and experience which would provide an equivalent background. Medical terminology training required. Certain contracts require a master’s degree. Preferred Skills, Capabilities and Experiences: + Experience in a behavioral health setting + Experience with Claims/Billing/Coding + Proficiently in Microsoft Excel + Ability to multitask and toggle between systems + Detail oriented + 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. Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Be part of an Extraordinary Team Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading. We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact? 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. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealthinc.com. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contactability@icareerhelp.comfor assistance. EEO is the LawEqual Opportunity Employer / Disability / Veteran Please use the links below to review statements of protection from discrimination under Federal law for job applicants and employees. + EEO Policy Statement + EEO is the Law Postero + EEO Poster Supplement-English Version + Pay Transparency + Privacy Notice for California Residents Elevance Health, Inc. is an E-verify Employer Need Assistance?Email us (elevancehealth@icareerhelp.com) or call 1-877-204-7664

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