Representative II

Tittle: Representative
Location : Woonsocket RI 02895
Duration :11/02/2026 to 10/03/2027
Pay $20.00 to $28.28
Duties:
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.
Experience:
Experience:
o Minimum of 6+ months customer service, healthcare, pharmacy, call center, or related experience.
Education:
o Verifiable High School Diploma or GED required.
Skills and Abilities:
o Strong verbal and written communication skills.
o Ability to problem-solve and manage multiple concrete variables in standardized situations.
o Proficiency navigating multiple computer systems simultaneously in a Windows-based environment.
o Ability to interpret work instructions delivered through multiple systems and formats.
o Ability to perform basic mathematical calculations.
o Typing ability of 30 WPM or greater.
Preferred Qualifications
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. through inquiries to ensure deep understanding of the business and deliver accurate results
Education:
High School Diploma or GED required. Associates degree in Business, Accounting or equivalent work experience preferred.