Medicare Representative II {167877}

Job Title: Medicare Representative II {167877}
Start Date: May 11, 2026
Pay Rate: $20.28/hr

Schedule

• Working Hours: Monday – Friday between 7:00 AM – 8:00 PM CST
• Weekend Rotation Required
• Training Schedule: Monday – Friday 8:00 AM – 4:30 PM CST
• Schedule flexibility required for evenings, weekends, and holiday coverage.

Position Overview

The Medicare Representative II works closely with healthcare providers to process prior authorizations (PA) and drug benefit exception requests in accordance with Medicare Part D CMS regulations on behalf of the client.

This role requires reviewing requests, gathering additional information from providers, and ensuring all coverage determinations are processed accurately and in compliance with regulatory guidelines. Representatives must apply plan criteria using internal systems and documented work instructions while maintaining high-quality customer service.

Key Responsibilities

• Process prior authorization (PA) and drug benefit exception requests for Medicare Part D members.
• Review and apply plan criteria using internal systems and work instructions.
• Conduct research and contact healthcare providers via phone to obtain necessary clinical or administrative information.
• Accurately document and complete all required steps to resolve and close cases .
• Identify and correct issues within the processing workflow.
• Provide phone assistance to initiate or resolve coverage requests.
• Escalate complex cases to Coverage Determinations and Appeals clinical pharmacists and management when necessary.
• Ensure strict compliance with CMS regulations, department standards, and internal policies .
• Maintain high levels of accuracy, productivity, and quality assurance standards .

Required Skills & Competencies

Healthcare & Call Center Experience

• Demonstrated ability to manage high workloads in healthcare call centers or healthcare-related environments.
• Familiarity with insurance plans including Commercial, Medicare, and Medicaid.
• Understanding of pharmacy benefit management (PBM) processes is preferred.

Technical Proficiency

• Strong computer skills with the ability to navigate multiple software systems simultaneously.
• Comfortable working within various internal databases and case management tools.

Communication Skills

• Excellent verbal and written communication skills.
• Strong active listening and problem-solving abilities.
• Professional, empathetic communication style when interacting with healthcare providers and patients.

Analytical & Problem-Solving Skills

• Ability to analyze case details and determine appropriate next steps.
• Strong attention to detail and accurate data entry skills to maintain compliance and avoid processing errors.

Work-From-Home Readiness

• Comfortable working independently in a remote environment.
• Experience using collaboration tools such as:
• Microsoft Teams
• Video conferencing platforms
• Email and messaging tools
• Must be webcam-ready when required.

Technical Requirements (Remote Work)

Employees must maintain a dedicated home workspace with:

• Wired Ethernet connection required (Wi-Fi not permitted)
• Reliable internet service with minimum speeds:
• 25 Mbps download
• 5 Mbps upload

Compliance & Professional Expectations

• Strict adherence to HIPAA regulations and patient privacy standards.
• Maintain compliance with CMS guidelines and internal procedures.
• Follow company attendance policies and remain fully engaged throughout scheduled shifts without personal distractions.

Minimum Qualifications

• 2+ years of healthcare or healthcare call center experience, including:
• Problem resolution
• Business writing
• Customer service
• Quality improvement processes
• 6 months of remote/virtual work experience where the supervisor is not physically present
• 6 months of high-volume call center experience (required)
• 6 months of PBM or pharmaceutical-related experience (strongly preferred)