Utilization Management Representative II at Elevance Health

Costa Mesa, California, United States

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Not SpecifiedCompensation

Junior (1 to 2 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Behavioral HealthIndustries

Requirements

HS diploma or equivalent
Minimum of 2 years customer service experience in a healthcare-related setting
Medical terminology training (or any combination of education and experience providing equivalent background)

Responsibilities

Manage incoming calls from clients needing mental health and substance use services, including triage, opening cases, and authorizing sessions
Determine contract and benefit eligibility; provide referral authorization for outpatient services
Obtain intake (demographic) information from caller
Conduct thorough radius search in Provider Finder and follow up with provider on referrals given
Refer cases requiring clinical review to a nurse reviewer; handle referrals for specialty care
Process incoming requests, collect information needed for review from providers, utilizing scripts to screen basic and complex requests for services
Verify benefits and/or eligibility information
Act as liaison between Medical Management and internal departments
Respond to telephone and written inquiries from clients, providers, and in-house departments
Conduct clinical screening process

Skills

Utilization Management

Call Management

Triage

Benefit Verification

Eligibility Determination

Intake Processing

Provider Referral

Case Authorization

Mental Health Services

Substance Use Disorder

Elevance Health

Integrated health services and digital platform

About Elevance Health

Elevance Health focuses on enhancing the health of individuals throughout their lives by evolving from a traditional health benefits organization into a comprehensive health partner. The company serves over 118 million people, providing support at every stage of health through an integrated approach that addresses a wide range of health needs. Their services are backed by advanced capabilities and a digital health platform that streamlines access to care. Unlike many competitors, Elevance Health emphasizes a holistic view of health, aiming to redefine health and improve community well-being. The ultimate goal is to make health improvements accessible to everyone.

Indianapolis, IndianaHeadquarters

1944Year Founded

$309.4MTotal Funding

IPOCompany Stage

Enterprise Software, Social Impact, HealthcareIndustries

10,001+Employees

Benefits

Medical, dental, & vision insurance

401(k) + match

Paid holidays

Paid Time Off

Incentive bonus programs

Stock purchase plan

Life insurance

Wellness Programs

Financial education resources

Adoption & Surrogacy Assistance

Dependent-care Flexible Spending Account (DCFSA)

Parental Leave

Parental Transition Week

Critical Caregiving Leave

Risks

Departure of CFO John Gallina may create a gap in financial leadership.

Lawsuit against CMS over MA Star Ratings could lead to financial penalties.

CareBridge integration may face operational challenges, disrupting service delivery.

Differentiation

Elevance Health integrates whole health approach with digital health platform for comprehensive care.

Acquisition of CareBridge enhances home health services within Carelon division.

Strategic partnership with Clayton, Dubilier & Rice aims to innovate primary care delivery.

Upsides

AI integration in home health services can reduce hospital readmissions and improve outcomes.

Predictive analytics support early disease detection, aligning with Elevance's whole health approach.

Telehealth expansion offers opportunities to reach more patients remotely.

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