Afterhours Utilization Management Representative I

About the role

This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office.

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. - Associates in this role are expected to have the ability to multi-task, including handling calls, texts, facsimiles, and electronic queues, while simultaneously taking notes and speaking to customers. - Additional expectations to include but not limited to: Proficient in maintaining focus during extended periods of sitting and handling multiple tasks in a fast-paced, high-pressure environment; strong verbal and written communication skills, both with virtual and in-person interactions; attentive to details, critical thinker, and a problem-solver; demonstrates empathy and persistence to resolve caller issues completely; comfort and proficiency with digital tools and platforms to enhance productivity and minimize manual efforts.

Requirements

Requires HS diploma or GED and a minimum of 1 year of customer service or call-center experience; or any combination of education and experience which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences

- Experience in a call center / call queue environment strongly preferred. - Medical terminology training and experience in medical or insurance field preferred.

Benefits

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.

Pay

Commensurate with experience.

Schedule

Fri/Sat/Sun/Mon, 1 AM - 11:30 AM EST