Utilization Management Nurse Jobs in Decatur, GA

Utilization Management Representative II - Benefit Investigation

Virtual: 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.

• 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.

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.

Work hours: Monday - Friday, 8:30 - 5pm EST, with flexibility to work 11:30 - 8pm EST during training period of 8-12 weeks.

The Utilization Management Representative II - Benefit Investigation is responsible for managing incoming calls, including triage, opening of cases and authorizing sessions.

How you will 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 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.

• Certain contracts require a Master's degree.

Preferred Skills, Capabilities and Experiences:

• Experience working in health insurance or with a managed care organization is preferred.

• Prior knowledge in infusion pharmacy or benefit investigation is strongly preferred.

• Ability to self-start, be coachable and flexible is strongly preferred.

• Prior experience with navigating multiple systems, partners, and internal & external customers is strongly preferred.

• Experience working with the CPR+ platform or CareTend platform is a plus.

• Candidates in alternate locations are welcome to apply provided they reside within commuting distance of a Pulse Point office location.

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 for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

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 contact elevancehealthjobssupport@elevancehealth.com for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.