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Posted 2 months ago
Requirements and responsibilities
You must be comfortable working CST hours as outlined below.
Top Must-Haves for This Role:
- High-Volume Healthcare Call Center Experience (Required):
- You need a minimum of 2 years of healthcare and/or health call center experience. Candidates without this will be rejected.
- You need a minimum of 6 months of high-volume call center experience. The team averages 80–100 inbound calls per day.
- You must have experience handling inbound calls only.
- You need a proven ability to work in a fast-paced, regulated, compliance-driven environment.
- You must be comfortable sitting for long periods with a handset, as this is a true call-center role.
- Prior Authorization / PBM / Pharmacy Benefit Experience:
- A strong plus is 6 months of PBM or pharmaceutical experience.
- You need knowledge of Medicare Part D.
- You need knowledge of prior authorizations.
- You need knowledge of appeals processes.
- You need knowledge of drug benefits.
- You need familiarity with insurance types (Commercial, Medicare, Medicaid).
Medicare Representative II Responsibilities:
- You will work closely with providers to process prior authorization (PA) and drug benefit exception requests on behalf of the client and in accordance with Medicare Part D Regulations.
- You must apply information provided through multiple channels to the plan criteria defined through work instruction.
- You will research and conduct outreach via phone to requesting providers to obtain additional information to process coverage requests and complete all necessary actions to close cases.
- You are responsible for research and correction of any issues found in the overall process.
- Phone assistance is required to initiate and/or resolve coverage requests.
- You will escalate issues to Coverage Determinations and Appeals clinical pharmacists and management team as needed.
- You must maintain compliance at all times and department standards.
- The position requires schedule flexibility, including rotations through nights, weekend, and holiday coverage.
Duties:
- You must have the ability to work in a fast-paced environment, handling a high volume of both inbound and outbound calls and working offline if the business needs.
- You need solid knowledge of prescription drug reimbursement, including insurance plan types, PBM and major medical benefits, prior authorizations, and appeals processing.
- You must be organized, detail-oriented, and able to document cases clearly and accurately in accordance with the program guidelines.
- Good communication skills are essential, both internal and external.
- You need knowledge of Medicare benefits, enrollments, and LIS assistance.
- You will plan and organize work assignments, set priorities, and complete work with a minimum of supervision.
- You must adhere to the service policy and principles of the company, as well as the program guidelines set by the department.
- You will participate in cross-training to perform all roles within the department.
- You will communicate effectively and professionally with our program partners to assure the best possible service for our patients and partners.
- Other duties as assigned.
Physical Demands:
- You may sit seven (7) to ten (10) hours per day.
- It may be necessary to work extended hours as needed.
- Finger dexterity to operate office equipment is required.
- Visual acuity to see and read fine prints is required.
- Specific vision abilities required by this role include close vision, color vision, and the ability to adjust focus.
- You must be able to hear normal voice sounds.
- The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this role.
Work Environment:
- Work from home fully remote.
Experience:
- You need at least 2 years of healthcare and/or health call center experience that includes problem resolution, business writing, quality improvement, and customer service.
- You need 6 months of working in a virtual role where the supervisor is not physically in the same space.
- 6 months of PBM/pharmaceutical related work is strongly desired.
- 6 months of High-Volume Call Center is strongly required.
Position Summary:
- You will be responsible for training and working virtually.
- You will be responsible for utilizing multiple software systems to complete Medicare cases.
- You will be responsible for meeting or exceeding government mandated timelines.
- You will be responsible for complying with turnaround time, productivity, and quality standards.
- You will be responsible for conveying resolution to the beneficiary or provider via direct communication and professional correspondence.
- You will be responsible for acquiring and maintaining basic knowledge of relevant and changing Med D guidance.
Education:
- A High School Diploma or GED is required.
Optionally, you can add more information later (benefits, pre-screening questions, etc.)