Coverage Determination Representative II

Job Title: Coverage Determination Representative II
Location: Remote (Work from Home)
Duration: 6 Months+ Contract (High Potential for Extension or Full-Time Hire)
 
Pay Range: $20.27/hr. on W2
 
Start Date: November 10, 2025

Pay Structure: Supplier and client bill rates apply (contact for details)

Shift Hours:

• Training: Monday–Friday, 9:00 AM – 5:30 PM EST (First 8 weeks, mandatory)
• Post-Training: Rotating 8-hour shifts between 8:00 AM – 8:00 PM EST, including rotating weekends

 
Important Notes:

• Must be on camera during all virtual training, supervisor meetings, and team meetings
• Internet Speed Test screenshot required with resume: www.speedtest.net
• Must reside in the U.S. and not have been previously submitted or termed negatively on prior ramp roles (2023–2024)
• No certification/license required
• Must live in the stated location and time zone—include this at the top of the resume

 
Position Summary:
As a Coverage Determination Representative II, you will be responsible for processing Medicare Part D prior authorization (PA) and drug benefit exception requests. You will work closely with providers, use multiple software platforms, and ensure compliance with CMS regulations and internal quality standards. This role requires strong attention to detail, data entry capabilities, and communication skills in a fast-paced, accuracy-driven remote environment.
 
Primary Responsibilities:

• Complete Medicare Part D prior authorization case reviews within required turnaround times
• Utilize multiple systems to gather and process case information
• Perform data entry and document management with high accuracy
• Conduct outbound calls to providers to collect missing data
• Interpret work instructions, Medicare guidelines, and plan criteria
• Communicate with internal clinical pharmacists or management as needed
• Work both independently and collaboratively in a fully remote setting
• Maintain all regulatory and procedural compliance (CMS, internal standards)
• Flexibly adapt to rotating shift schedules, including nights, weekends, and holidays

 
Candidate Requirements:
Must-Haves:

• High School Diploma or GED
• Minimum 2 years of experience in healthcare data entry, customer service, or medical administration
• Strong computer skills with ability to work across multiple systems and dual monitors
• Excellent verbal and written communication skills
• Attention to detail and ability to meet productivity standards
• Must be able to sit and work uninterrupted during scheduled shifts
• Dedicated, quiet home workspace with wired internet (25 Mbps down / 5 Mbps up minimum)

Preferred:

• Previous remote/work-from-home experience
• Background in pharmacy, healthcare, or medical terminology
• Experience in Medicare Part D, prior authorizations, or insurance adjudication
• Experience in compliance-driven roles and handling sensitive data
• Associate’s Degree or some college coursework preferred

 
Screening Questions (to confirm with candidate and include on resume):

• Any conflicts with the training schedule (M–F, 9am–5:30pm EST, first 8 weeks)?
• Any conflicts with rotating 8-hour shifts between 8am–8pm EST and rotating weekends?
• Do you have a dedicated, quiet workspace and wired internet (with speed test screenshot)?
• Are you able to sit and focus for a full 8–12 hour shift?
• Do you have data entry and multi-application navigation experience?
• Do you have a pharmacy or medical background?
• Have you successfully worked independently in a productivity-driven role?
• Do you feel you bring engagement and a positive attitude to remote assignments?

 
Interview Process:

• Virtual Interview via Microsoft Teams or Phone
• Final candidates must pass state-specific caregiver background check (wet signature required for Wisconsin)