Prior Authorization Representative

Duration: 09/22/2025 to 03/21/2026Pay range: $17.00 - $18.00Location: RemotePosition Summary: The Coverage Determination Representative II will work closely with providers to process prior authorization (PA), and drug benefit exception requests 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 MS Excel. 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: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 resultsEducation:High School Diploma or GED required.