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

Afterhours Utilization Management Representative I

Key skills