Utilization Management Representative

Welcome to Elevance Health! We are a leading healthcare organization dedicated to providing high-quality and cost-effective care to our members. We are currently seeking a highly motivated and detail-oriented Utilization Management Representative to join our team. In this role, you will play a critical part in ensuring our members receive the appropriate level of care and services. If you are passionate about making a positive impact on people's lives and have a strong background in healthcare utilization management, we want to hear from you. Keep reading for more details on the qualifications and responsibilities for this position.

1. Conduct utilization management activities to ensure appropriate utilization of healthcare services for Elevance Health members.
2. Review and evaluate medical records, treatment plans, and other relevant information to determine the medical necessity and appropriateness of requested services.
3. Communicate with healthcare providers, facilities, and members to gather necessary information and discuss utilization management decisions.
4. Provide timely and accurate utilization management decisions based on established guidelines and policies.
5. Collaborate with other members of the healthcare team to develop and implement care plans that meet the needs of our members.
6. Maintain accurate and detailed documentation of utilization management activities, including approvals, denials, and appeals.
7. Stay up-to-date on industry best practices and regulatory requirements related to utilization management.
8. Identify and report any potential quality of care concerns to the appropriate parties.
9. Assist with the development and implementation of utilization management policies and procedures.
10. Participate in training and development opportunities to enhance utilization management skills and knowledge.
11. Maintain confidentiality and adhere to HIPAA regulations in all utilization management activities.
12. Foster positive relationships with healthcare providers, facilities, and other stakeholders to promote effective utilization management processes.
13. Collaborate with other departments, such as claims and customer service, to resolve utilization management-related issues.
14. Participate in meetings and presentations to provide updates on utilization management activities and outcomes.
15. Act as a liaison between Elevance Health and external agencies, such as insurance companies and regulatory bodies, regarding utilization management inquiries or audits.

According to JobzMall, the average salary range for a Utilization Management Representative in Overland Park, KS, USA is $55,000 to $65,000 per year. However, this can vary depending on factors such as experience, education, and the specific company or industry the representative works for. Additionally, some companies may offer additional benefits and bonuses that can also impact the overall salary.

Elevance Health, Inc. is an American health insurance provider. The company's services include medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans through affiliated companies such as Anthem Blue Cross and Blue Shield, Empire BlueCross BlueShield in New York State, Anthem Blue Cross in California,Wellpoint, and Carelon.It is the largest for-profit managed health care company in the Blue Cross Blue Shield Association. As of 2022, the company had 46.8 million members within their affiliated companies' health plans. Prior to June 2022, Elevance Health was named Anthem, Inc.