You have opted out of job matches in .
To undo this, go to the 'Skills and Interests' section of your preferences.
Posted 19 days 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.)