Coverage Determination Representative II

fully remote job

12 months contract

Woonsocket, RI, 02895

Position Summary

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

In this role, Coverage Determination Representative II, contractors will be responsible for:

Utilizing multiple software systems to complete Medicare Prior Authorization 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. Associates degree in Business, Accounting or equivalent work experience preferred.

Experience :

2 years experience.

Strong Attention to detail

Excellent verbal and written communication and interpersonal skills w/ ability to maintain patient confidentiality

Proficient computer skills and the ability to navigate in a Windows based environment

Ability to follow directions, and adapt in dynamic work environment; ability to adapt to change and remain flexible

Ability to work in a high pressure, time sensitive environment

Project a professional business image, through phone interaction as well as internal communications

Demonstrated problem-solving ability and attention to detail

Demonstrated sense of urgency with assignments 9.Strong organizational skills

Strong telephone skills

Ability to read and understand pharmacy/medical terminology

Ability to read, analyze and interpret general business correspondence, technical procedures and governmental regulations.

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

Ability to interpret a variety of work instructions provided through a variety of mediums

Ability to anticipate needs and resolve issues with urgency

Ability to consistently meet quality and production standards

Displays confidence in the ability to learn complex material

Demonstrates intellectual curiosity through inquiries to ensure deep understanding of the business and deliver accurate results

Note :

8hr Shift Mon- Fri 8a-8p EST, rotating weekends. Training hours M-F 9a-5:30p EST initially

Fully remote (never coming onsite)

Safety Sensitive Role

Attendance is extremely important, especially during the initial 8 weeks of training. The new hire must be available M-F from 9am-5:30pm EST for the first 8 weeks (no vacation time planned).

After training, our hours of operation are 8-8 EST M-F with rotating weekend schedules. – they must be available for the rotating weekend.

This is a work from home (WFH) position; must have a dedicated quiet, separate space in which to work with wired internet meeting 25mbps min download and 5mbps minimum upload speed. Previous WFH experience is preferred.

Must be able to sit and focus on work for the duration of shift.

Data entry and navigating multiple computer applications while utilizing two screens is the primary function of job (possible outbound calls needed). A job history demonstrating this is recommended.

Pharmacy or medical background is preferred.

Successfully worked independently in a data entry, productivity driven role is preferred

As a company we strive for a team that is engaged and positive so candidates that demonstrate this would be ideal

Opportunity for full-time employment contingent on performance

Hours of operation 8-8 EST M-F with rotating weekend schedules