Representative II

Job Title: Representative II
Job Location: Remote, RI
Job Duration: 5-6 Months (possibility of extension)
Shift: 9:00am - 5:30pm EST. Working hours will be a rotating shift between the hours of 8:00am - 8:00pm 
Payrate: $20.27/ hr on w2

Job Summary:

• 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.
• Must apply information provided through multiple channels to the plan criteria defined through work instruction.
• 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.
• Escalate issues to Coverage Determinations and Appeals Learning Advocates and management team as needed.
• Must maintain compliance at all times 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.
• Opportunity for full-time employment contingent on performance.
• Virtual interviews with supervisors via WebEx or phone.
• Hours of operation 8-8 EST M-F with rotating weekend schedules.

Duties:

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

Education:

• High School Diploma or GED required.
• Bachelor’s degree in related field or equivalent work experience preferred.

Experience:

• Customer service focus.
• Basic experience in MSWord and MSExcel.
• Familiar with medical terminology and knowledge of medical coding.
• Ability to read and interpret billing documents.
• The position also requires an extensive amount of data entry work.
• Accountable and results driven.
• Critical thinker/problem solver.
• Receptive to constructive feedback and flexible in adapting to change.
• Ability to effectively plan, prioritize, and organize time and workload.
• Ability to execute successfully in a deadline-oriented, fast-paced, highly-regulated environment.
• Ability to sit at desk/station and focus on reviews for entire shift.
• Proficient in navigation of multiple computer applications.
• Proficient use of keyboard, mouse and ability to navigate 2 workstation monitors.
• Ability to type more than 30 WPM.
• Six months of PBM/pharmaceutical related work strongly desired.
• At least two years of general business experience that includes problem resolution, business writing, quality improvement and customer service.