Representative II

Our client, a Retail Pharmacy company, is looking for a Representative II for their Remote location.

Responsibilities:

• 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:
• As a Rep II, Operations, you will support Medicare members, prescribers, and providers by processing coverage-related requests across both phone and fax (offline) channels.
• This role integrates responsibilities previously segmented by channel (phone vs. fax) and line of business (Medicare Part D and applicable Medicare Part B processes), reflecting the organization's modularized training model in which colleagues progressively learn, practice, and apply end to end skills before fully transitioning to production work.
• Responsible for accurate case setup, review, outreach, documentation, and timely resolution of requests in accordance with Medicare guidelines, CMS-mandated timelines, and internal quality standards.
• Demonstrate strong attention to detail, professional verbal and written communication skills, and the ability to problem-solve in a highly regulated, fast-paced environment.
• Work will be performed through a combination of inbound and outbound phone interactions and fax-based casework.
• This role reflects an integrated Rep II model aligned with modularized training.
• Colleagues are trained across both phone and fax-based workflows and progressively apply learned skills through practice before full production deployment.
• Channel assignment (phone vs. offline work) and case mix may vary based on business needs, proficiency, and operational demand.
• Any remaining discrepancies between legacy role definitions (phone vs. fax, Part D vs. Part B) can be addressed individually without altering the core scope of this position.
• Case Intake, Review, and Processing (Phone & Fax)
• Process incoming coverage-related requests (e.g., prior authorizations, coverage determinations, drug benefit exceptions, appeals) via phone and fax from members and prescribers.
• Accurately set up cases, review documentation, and apply work instructions to ensure correct and timely processing.
• Read, analyze, and interpret business correspondence, technical procedures, and Medicare regulations to support decision-making.
• Outreach and Information Gathering
• Conduct outbound calls to members and providers to obtain missing or additional information required to complete requests.
• Communicate clearly, professionally, and empathetically while projecting a positive business image.
• Documentation, Accuracy, and Compliance
• Provide clear, concise, and accurate documentation of all case activity across systems.
• Ensure all cases are properly closed and meet CMS-mandated timelines, department productivity expectations, and quality standards.
• Identify and research issues in the overall process and correct errors when identified.
• Escalation and Collaboration
• Raise complex issues or clinical questions to Coverage/Organization Determination Clinical Pharmacists or management as appropriate.
• Collaborate with peers, trainers, and leaders while progressing through modular training and skill expansion.
• Continuous Learning and Development
• Acquire and maintain working knowledge of evolving work instructions, systems, and Medicare guidance (Part D and applicable Part B processes).
• Participate in coaching, feedback, and development discussions with direct leadership. has context menu

Requirements:

• Minimum of 6+ months customer service, healthcare, pharmacy, call center, or related experience.
• Strong verbal and written communication skills.
• Ability to problem-solve and manage multiple concrete variables in standardized situations.
• Proficiency navigating multiple computer systems simultaneously in a Windows-based environment.
• Ability to interpret work instructions delivered through multiple systems and formats.
• Ability to perform basic mathematical calculations.
• Call center experience.
• Experience in a PBM, managed care, or healthcare environment.
• Experience handling confidential patient or member information.
• Familiarity with multi-system workflows (e.g., claims platforms, case management systems, internal databases).
• Pharmacy Technician Certification (CPhT) or related education.
• High School Diploma or GED required. Associates degree in Business, Accounting or equivalent work experience preferred.

Why Should You Apply?

• Health Benefits
• Referral Program
• Excellent growth and advancement opportunities