Utilization Management Representative II

Elevance Health

. Manage incoming calls, including triage, case opening, session authorization, and support for timely prior authorization decisions .

Posted 9/16/2026full-timeCincinnati • Florida • United StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in managing prior authorization processes, including case opening, benefit eligibility verification, and clinical documentation review. Proficient in utilizing Electronic Medical Records systems and understanding medical insurance guidelines to facilitate effective communication between providers and internal departments.

Highest-signal resume keywords

Prior Authorization ManagementMedical TerminologyHCPCS CodingElectronic Medical Records (EMR)Customer Service Experience

ATS Keywords

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Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

ICD-10 CodingClinical Criteria GuidelinesExcelBenefit VerificationDemographic IntakeAuthorization SubmissionClaims ProcessingClinical ScreeningDocumentation ReviewReferral Coordination

Soft Skills

CommunicationInterpersonal SkillsProblem-SolvingOrganizational Skills

Tools & Technologies

EpicWebRxCPR+CoverMyMedsAvaility

Industry Keywords

HealthcareMedicareMedicaidPBMsBuy-and-Bill ModelsAuthorization Status UpdatesClinical ReviewPatient Care

About the role

Key responsibilities & impact

Manage incoming calls, including triage, case opening, session authorization, and support for timely prior authorization decisions
Manage incoming post-service claims work, including specialty infusion prior authorization requests for high-cost therapies
Determine contract and benefit eligibility
Provide authorization for inpatient admission, outpatient precertification, prior authorization, and post-service requests
Submit, track, and follow up on authorizations
Obtain demographic intake information from callers
Conduct radius searches in Provider Finder and follow up with providers on referrals
Refer cases requiring clinical review to nurse reviewers and handle specialty-care referrals
Process incoming requests and collect information from providers using scripts to screen precertification and prior authorization requests
Review supporting documentation, including clinical notes and labs when applicable, against payer-specific criteria
Verify benefits and eligibility, coordinating with commercial insurance, Medicare/Medicaid, and PBMs
Act as liaison between Medical Management and internal departments
Respond to telephone and written inquiries from clients, providers, and in-house departments
Communicate authorization status updates to providers and clinical staff
Support denial follow-up by coordinating additional medical-necessity information
Conduct clinical screening and document authorization details, including approval dates and reference numbers, in the system

Requirements

What you’ll need

HS diploma or equivalent
Minimum of 2 years customer service experience in a healthcare-related setting
Medical terminology training
Any combination of education and experience which would provide an equivalent background
Intermediate experience with Excel is strongly preferred
Experience with HCPCS (J-codes), ICD-10 coding, and clinical criteria guidelines such as InterQual or MCG is strongly preferred
Experience with Electronic Medical Records (EMR) systems such as Epic, WebRx, or CPR+ and prior authorization portals such as CoverMyMeds or Availity is preferred
Understanding of major medical insurance, PBMs, buy-and-bill models, Medicare Parts B and D, and Medicaid guidelines is preferred
Ability to work 8:00 am–5:00 pm EST, Monday to Friday
Candidates must reside within a reasonable commuting distance from the posting location(s), unless an accommodation is granted as required by law
New candidates in certain patient/member-facing roles must become vaccinated against COVID-19 and Influenza, unless an acceptable explanation is provided

Benefits

Comp & perks

merit increases
paid holidays
Paid Time Off
incentive bonus programs
medical benefits
dental benefits
vision benefits
short-term disability benefits
long-term disability benefits
401(k) + match
stock purchase plan
life insurance
wellness programs
financial education resources
Virtual full-time work, except for required in-person training sessions
Flexible work-life integration
COVID-19 and Influenza vaccination support/requirements for certain roles