Medicare Coverage Determination Representative

Coverage Determination Representative, Medicare Remote US Temporary Assignment, 1 year Hours of operation 8-8 EST M-F with rotating weekend schedules Required to have Medicare and Prior Authorization experience. Job Summary: The Coverage Determination Representative will work closely with providers to process prior authorization (PA) and drug benefit exception requests for multiple clients or lines of business 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 Learning Advocates and management team as needed. Must maintain compliance at all times with CMS and department standards. Position requires schedule flexibility and additional cross training to learn all lines of business. Flexibility for movement to different parts of the business to support volume where needed. In this role, you will be responsible for: ∙ Utilizing multiple software systems to complete Medicare appeals 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, outbound calls, and professional correspondence ∙ Acquiring and maintaining basic knowledge of relevant and changing Med D guidance Minimum Qualifications: 1 year of health insurance or pharmacy PBM experience 1 year of experience with Medicare, Medicaid or health insurance 1 year of customer service experience Preferred Qualifications: ∙ Accountable and results driven ∙ Critical thinker/problem solver ∙ Receptive to constructive feedback and flexible in adapting to change ∙ Ability to effectively plan, prioritize, and organize time and workload ∙ Ability to execute successfully in a deadline-oriented, fast-paced, highly-regulated environment ∙ Ability to sit at desk/station and focus on reviews for entire shift ∙ Proficient in navigation of multiple computer applications ∙ Proficient use of keyboard, mouse and ability to navigate 2 workstation monitors ∙ Ability to type more than 30 WPM High School Diploma or GED Job Type: Temporary Pay: $17.75 per hour Benefits: 401(k) 401(k) matching Dental insurance Flexible schedule Health insurance Life insurance Paid time off Vision insurance Schedule: 8 hour shift Monday to Friday Weekends as needed Education: High school or equivalent (Required) Experience: Prior Authorization: 1 year (Required) Pharmacy benefit management: 1 year (Preferred) Customer service: 2 years (Required) Healthcare: 2 years (Required) Medicare: 1 year (Required) Work Location: Remote