Job description

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

Representative II

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