Representative II

Top 3 MUSTHAVES for This Role
1. HighVolume Healthcare Call Center Experience (Required)
Minimum 2 years healthcare and/or health call center experience - if candidate does not have this, then they will be rejected.
Minimum 6 months highvolume call center experience
Team averages 80100 inbound calls per day
Experience handling inbound calls only
Proven ability to work in a fastpaced, regulated, compliance-driven environment
Must be comfortable sitting for long periods with a handset this is a true callcenter role
2. Prior Authorization / PBM / Pharmacy Benefit Experience
Strong plus: 6 months PBM or pharmaceutical experience
Knowledge of:
Medicare Part D
Prior authorizations
Appeals processes
Drug benefits
Familiarity with insurance types (Commercial, Medicare, Medicaid)
3. Strong Technical & Remote Work Capability
Ability to navigate multiple systems and software platforms simultaneously
Previous remote/virtual work experience (minimum 6 months)
Ability to maintain required wired internet connection and private, HIPAAcompliant workspace
Strong communication skills, including documentation of complex case details

***Candidate Questionnaire (Place at Top of Resume)***
Please include the following responses at the top of your resume:
1. Do you have at least 2 years of healthcare and/or healthcare call center experience?
2. Do you have experience handling highvolume inbound calls?
What is the average number of calls per day you are comfortable handling?
3. Do you have experience with Prior Authorizations, PBM processes, or Medicare Part D?
4. Have you worked in a remote/virtual role for at least 6 months without an onsite supervisor?
5. Do you have a dedicated private workspace free from noise and distractions?
6. Do you have reliable wired internet (minimum 25 Mbps down / 5 Mbps up)?
Please attach a screenshot of the speed test at the top of your resume.
7. Are you comfortable navigating multiple systems and documentation tools simultaneously?
8. Do you have experience handling sensitive patient information and maintaining HIPAA compliance?
9. Are you able to meet strict timelines, productivity metrics, and quality standards?
10. Are you willing and able to work nights, weekends, and holiday rotations as required?
11. If applicable, do you have childcare arrangements in place to support the required schedule?
12. Are you comfortable being on camera?
Routine webcam checks are performed to ensure workfromhome space meets HIPAA standards.

Training Requirements (Mandatory)
Schedule: MondayFriday, 8:00 AM 4:30 PM CST
Duration: First 9 weeks
Attendance: No prescheduled time off allowed during the first 9 weeks
Must be on camera for the full duration of training

PostTraining Schedule
Must be available for an open schedule:
MondayFriday, 7:00 AM 8:00 PM CST
Rotating weekends (every 34 weeks)
Shifts are assigned based on business needs candidates cannot choose their shift.

The Medicare Representative II will work closely with providers to process prior authorization (PA), and drug benefit exception requests on behalf of *** 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.

Role-Specific Experience: Demonstrated success managing high workloads in healthcare call center and/or healthcare-related environments. Familiarity with diverse insurance plans (Commercial, Medicare, Medicaid) and pharmacy benefit management processes.

Technical Proficiency: Competence in using the computer and navigating multiple software platforms and systems.

Communication Excellence: Exceptional written and verbal communication skills, including active listening and the ability to convey complex information clearly. Professional and empathetic customer service approach when interacting with healthcare providers and patients.

Analytical & Problem-Solving Skills: Proven ability to assess cases, troubleshoot challenges, and apply critical thinking to determine best outcomes. Precision in data entry to maintain compliance and prevent errors.

Work-From-Home Readiness: Proficiency with remote collaboration tools such as Microsoft Teams, video conferencing platforms, and email and Webcam ready whenever needed. Ability to work independently and manage time effectively in remote environment.

Internet & Tech Requirements

This position requires a dedicated home workspace with a wired ethernet connection (Wi-Fi is not permitted) and reliable internet service of at least 25 mbps download and 5 mbps upload. You must be able to maintain this standard throughout your employment.

Compliance & Confidentiality: Demonstrated adherence to HIPAA regulations and patient privacy protocols.

Attendance & Engagement Commitment: Commitment to adhering to the companys attendance policy and maintaining full engagement throughout the entire scheduled shift, free from personal distractions.

Position Summary:

In this role, you will be responsible for:
Training and working virtually
Utilizing multiple software systems to complete Medicare case

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

Duties:

Ability to work in a fast-paced environment, handling high volume of both inbound and outbound calls and working offline if the business needs. Solid knowledge of prescription drug reimbursement, including insurance plan types, PBM and major medical benefits, prior authorizations and appeals processing. Must be organized, detail-oriented and able to document cases clearly and accurately in accordance with the program guidelines. Good communication skills are essential, both internal and external. Knowledge of Medicare benefits, enrollments and LIS assistance. Plans and organizes work assignments, set priorities and completes work with a minimum of supervision. Adheres to the service policy and principles of the company, as well as the program guidelines set by the department. Participates in cross-training to perform all roles within the department. Communicates effectively and professionally with our program partners to assure the best possible service for our patients and partners. Other duties as assigned. Physical Demands: May sit seven (7) to ten (10) hours per day. May be necessary to work extended hours as needed. Finger dexterity to operate office equipment required. Visual acuity to see and read fine prints. Specific vision abilities required by this role include close vision, color vision and the ability to adjust focus. Must be able to hear normal voice sounds. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this role. Work Environment: Work from home fully remote.

Experience:

At least 2 years of healthcare and /or Health call center experience that includes problem resolution, business writing, quality improvement and customer service.
6 months of working in a virtual role where the supervisor is not physically in the same space
6 months of PBM/pharmaceutical related work strongly desired
6 months of High-Volume Call Center strongly required.

Education:

High School Diploma or GED required.