Afterhours Utilization Management Representative I

Responsibilities

• 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
• Refers cases requiring clinical review to a Nurse reviewer
• Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate
• Responds to telephone and written inquiries from clients, providers and in-house departments
• Conducts clinical screening process
• Authorizes initial set of sessions to provider
• Checks benefits for facility based treatment
• Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner
• Multi-tasking, including handling calls, texts, facsimiles, and electronic queues, while simultaneously taking notes and speaking to customers
• Proficient in maintaining focus during extended periods of sitting and handling multiple tasks in a fast-paced, high-pressure environment
• Comfortable and proficient with digital tools and platforms to enhance productivity and minimize manual efforts
• Performs other duties as assigned

• Requires HS diploma or GED and a minimum of 1 year of customer service or call‑center experience
• Experience in a call center / call queue environment strongly preferred
• Medical terminology training and experience in medical or insurance field preferred
• Strong oral, written and interpersonal communication skills
• Problem‑solving skills
• Facilitation skills
• Analytical skills

Demonstrates expertise in managing customer inquiries and claims processing within a fast-paced call center environment, utilizing strong communication and problem‑solving skills. Proficient in medical terminology and customer service practices to ensure effective coordination and support.