Customer Service Representative (Healthcare)

Job Title: COVERAGE DETERMINATION REPRESENTATIVE

Location: Fully remote

Duration: 12 months

Schedule: 8hr Shift Mon- Fri 8a-8p EST, rotating weekends. Training hours M-F 9a-5:30p EST initially

Description:

• At least two years of general business experience that includes problem resolution, business writing, quality improvement and customer service.
• Preferred Qualifications:
• Six months of PBM/pharmaceutical related work strongly desired

• 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.
• Responsible for research and correction of any issues found in the overall process. Phone assistance is required to initiate and/or resolve coverage requests.
• Must apply information provided through multiple channels to the plan criteria defined through work instruction.
• The Coverage Determination Representative II will work closely with providers to process prior authorization (PA) and drug benefit exception requests for multiple clients or lines of business and in accordance with Medicare Part D CMS Regulations.
• Escalate issues to Coverage Determinations and Appeals Learning Advocates and management team as needed.
• Must always maintain compliance with CMS and department standards. Position requires schedule flexibility and additional cross training to learn all lines of business.
• Flexibility for movement to different parts of the business to support volume where needed.

Duties:

• Utilizing multiple software systems to complete Medicare appeals case reviews.
• Acquiring and maintaining basic knowledge of relevant and changing Med D guidance.
• Complying with turnaround time, productivity, and quality standards.
• Conveying resolution to beneficiary or provider via direct communication and professional correspondence
• Meeting or exceeding government mandated timelines

Experience:

• Accountable and results driven.
• Critical thinker/problem solver
• Receptive to constructive feedback and flexible in adapting to change.
• Ability to type more than 30 WPM.
• Ability to effectively plan, prioritize, and organize time and workload.
• Proficient in navigation of multiple computer applications
• Ability to sit at desk/station and focus on reviews for entire shift.
• Proficient use of keyboard, mouse, and ability to navigate 2 workstation monitors.
• Ability to execute successfully in a deadline-oriented, fast-paced, highly regulated environment.

Education:

High School Diploma or GED required.

• Bachelor’s degree in related field or equivalent work experience preferred.