Anticipated End Date:

2024-10-10

Position Title:

Utilization Management Representative Lead

Job Description:

Utilization Management Representative Lead

Location: Must live within 50 miles of a Florida PlustPoint

The Utilization Management Representative Lead is responsible for providing technical guidance to UM Reps who handle correspondence and assist callers with issues concerning contract and benefit eligibility for precertification, prior authorization of inpatient and outpatient services and post service requests.

How you will make an impact:

• Motivates and encourages UM Reps while providing technical guidance. Provides quality control services such as call monitoring and conducts UMR level I, II, and III audits for subsequent performance under NMIS and MTM standards.
• Suggests methods to improve productivity.
• Understands specific workflow, processes, departmental priorities and guidelines.
• Monitors daily phone activities to exceed NMIS standards and improve customer service levels.
• Assists in supervising the daily activities of a group of Behavioral Health Associates.
• Provides direction and guidance to less experienced team members.
• Assists manager with PTO scheduling and monitoring attendance.
• Handles escalated and unresolved calls from less experienced team members. Handles complex situations and ensures UM Reps are directed to the appropriate resources to resolve issues.
• Keeps team members informed of any changes.
• Assists management by identifying areas of improvement and recommends solutions.
• Keeps manager informed of changes or problems.
• Keeps departmental manuals up-to-date.
• Researches resources for report generation for manager and ancillary departments.
• Obtains, analyzes and presents statistical information as it relates to units of work, productivity, FTEs at work and time off.
• May provide input into hiring decisions and performance appraisals.

Minimum Requirements:

•  Requires HS diploma or equivalent and a minimum of 5 years related experience to include complex customer service or call center experience and medical terminology training; or any combination of education and experience which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

• Knowledge of health plans, including familiarity with prior authorization and precertification process; knowledge of contracts and strong knowledge of managed benefit programs strongly preferred.  
• Master's degree preferred. Certain contracts require a Master's degree.
• 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.

Job Level:

Non-Management Non-Exempt

Workshift:

Job Family:

CUS > Care Support

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. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

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. 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 [email protected] for assistance.