Utilization Management Representative II - Prior Authorization -BioPlus Specialty Pharmacy

Anticipated End Date:

2025-06-23

Position Title:

Utilization Management Representative II - Prior Authorization -BioPlus Specialty Pharmacy

Job Description:

Be Part of an Extraordinary Team

BioPlus Specialty Pharmacy is now part of CarelonRx (formerly IngenioRx), and a proud member of the Elevance Health family of companies. Together, CarelonRx and 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.

Title: Utilization Management Representative II - Prior Authorization

Location: TX-SAN ANTONIO, 4751 HAMILTON WOLF RD, STE 101

Onsite: This role requires associates to work from the posted locations full-time, enabling consistent face-to-face collaboration, teamwork, and direct engagement. This policy promotes an environment built on in-person interaction, communication, and immediate support.

Build the Possibilities. Make an extraordinary impact.

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

How you will make an impact:

Primary duties may include, but are not limited to:

• Efficiently process and submit prior authorization requests for 340B specialty medications according to payer-specific guidelines and protocols.

• Maintain and update patient spreadsheets to ensure accurate tracking of authorization statuses and documentation.

• 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.

• 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 Requirements:

• 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.

• 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.

• Certain contracts require a Master's degree.

Preferred Skills, Capabilities and Experiences:

• Minimum of 2 years of experience in healthcare or pharmacy services, with specific experience with pharmacy adjudication and prior authorizations strongly preferred.

• Knowledge of the 340B program and experience with specialty medications strongly preferred

• Certified Pharmacy Technician (CPhT) or related certification preferred.

• Strong organizational and multitasking skills, with meticulous attention to detail and problem-solving skills preferred.

• Excellent communication and interpersonal skills to liaise effectively with prescribers, pharmacy staff, and insurance companies preferred.

• Proficiency in using healthcare information systems and Microsoft Office applications preferred.

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.

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