Rep I, Clinical Services

MAX Client Bill Rate for this role = ***

This is a safety role.

***Please have the following at the top of each resume***
1
Do you understand that this is a fast paced call center position where you will be handling back to back inbound phone calls?
2
Do you have any time off during these training dates: (insert training dates)?
3
Do you understand that your post training shift will be randomly assigned between the hours of 8am and 8pm Central?
4
If it applies to you, you must have separate childcare arrangements during your scheduled shift
Any concerns meeting this requirement?
5
You must have a dedicated work area free of distractions to be HIPAA compliant
Any concerns meeting this requirement?
6
Please include a screen shot of internet speeds along with the resume.


The Rep I, Clinical Services takes in-bound calls from providers, pharmacies, members, etc providing professional and courteous phone assistance to all callers through the criteria based prior authorization process
Maintains complete, timely and accurate documentation of reviews
Transfers all clinical questions, escalations and judgement calls to the pharmacist team.


The Rep I, Clinical Services will also assist with other duties as needed to include but not limited to: outbound calls, reviewing and processing Prior Auth s received via fax and ePA, monitoring and responding to inquiries via department mailboxes and other duties as assigned by the leadership team.

Position Summary:

The Healthcare CD Representative II will work closely with providers to process prior authorization (PA), and drug benefit exception requests on behalf of Healthcare as the client 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 clinical pharmacists and management team as needed
Must maintain compliance at all times with CMS and department standards
Position requires schedule flexibility including rotations through nights, weekend and holiday coverage.

Duties:

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.

Experience:

2 years experience
1.Strong Attention to detail 2.Excellent verbal and written communication and interpersonal skills w/ ability to maintain patient confidentiality 3.Proficient computer skills and the ability to navigate in a Windows based environment 4.Ability to follow directions, and adapt in dynamic work environment; ability to adapt to change and remain flexible 5.Ability to work in a high pressure, time sensitive environment 6.Project a professional business image, through phone interaction as well as internal communications 7.Demonstrated problem-solving ability and attention to detail 8.Demonstrated sense of urgency with assignments 9.Strong organizational skills 10.Strong telephone skills 11.Ability to read and understand pharmacy/medical terminology 12.Ability to read, analyze and interpret general business correspondence, technical procedures and governmental regulations
13.Ability to identify and solve practical problems and deal with a variety of concrete variables in standardized situations
Ability to perform basic mathematic calculations maybe required 14.Ability to interpret a variety of work instructions provided through a variety of mediums 15.Ability to anticipate needs and resolve issues with urgency 16.Ability to consistently meet quality and production standards 17.Displays confidence in the ability to learn complex material 18.Demonstrates intellectual curiosity through inquiries to ensure deep understanding of the business and deliver accurate results

Education:

High School Diploma or GED required
Associates degree in Business, Accounting or equivalent work experience preferred.