Coverage Determination Representative II

Job Title: Coverage Determination Representative I
Location: San Antonio, TX – Hybrid (3 days onsite, 2 days remote)
Duration: 6 + Months (Possibilities of Extension)

Department: Coverage Determination and Appeals Operations

Duration: Contract
Positions Available: 12
Safety Sensitive: Yes
Bill Rate: [Redacted – for internal use only]
 
Shift Details:

• Training Schedule: Monday–Friday, 9:00 AM – 5:30 PM EST (8 weeks, no PTO during this period)
• Post-Training Schedule: Rotating 8-hour shifts between 8:00 AM – 8:00 PM EST, including rotating weekends and holidays
• Hybrid Model: Required to work onsite 3 days/week, remote 2 days/week
• Internet Requirement (Remote Days): Minimum 25 Mbps download, 5 Mbps upload (Wired connection only)
• Camera Requirement: Must be on camera for all training, supervisor, and team meetings

 
Key Responsibilities:

• Review faxed documents for accuracy and route to the appropriate workflow queue
• Utilize multiple software systems to create and manage Medicare Part D prior authorization case reviews
• Comply with CMS-mandated turnaround time, productivity, and quality standards
• Research and maintain accurate documentation of coverage determination/appeals requests
• Escalate clinical issues to pharmacists or management as appropriate
• Participate in process training and continuous feedback discussions
• Maintain updated knowledge of evolving Medicare Part D guidelines and internal procedures

 
Required Qualifications:

• Education: High School Diploma or GED
• Work Location Requirement: Must reside within commuting distance of the San Antonio office
• Computer Proficiency: Ability to navigate multiple systems and dual monitors for data entry
• Work Environment: Must have a dedicated, interruption-free workspace at home with wired internet
• Availability: Able to sit and focus for full shift, including weekend and holiday coverage as required

 
Preferred Experience:

• Previous experience in medical insurance, pharmacy, or healthcare administration
• Background in data entry, especially in a metrics-driven environment
• Prior experience working independently in a remote setting
• Demonstrated positive and professional attitude

 
Candidate Pre-Screening Requirements:
Please answer and include responses at the top of the resume:

• Do you have any conflicts with the required 8-week training schedule?
• Are you available for a rotating schedule between 8 AM–8 PM EST and rotating weekends?
• Do you have a quiet, dedicated workspace and wired internet? (Include speed test screenshot from www.speedtest.net)
• Are you able to sit and work uninterrupted during your entire shift?
• Do you have prior data entry experience using multiple applications/screens?
• Do you have a pharmacy or medical background?
• Have you worked successfully in an independent, remote, productivity-focused role?
• Do you bring a positive, engaged attitude to your work?

 
Interview & Hiring Timeline:

• Offers Extended by: October 13, 2025
• Offers Accepted by: October 16, 2025
• Last Day to Clear Requirements: October 31, 2025
• Start Date: November 10, 2025
• Interview Format: Virtual (Microsoft Teams or Phone)