Operations Representative II Medicare Coverage Support

JOB DESCRIPTION

Operations Representative II Medicare Coverage Support
Location: Remote Work From Home
Pay Rate: $20.27/hr W2
Start Date: September 7
Employment Type: Full-time contract with potential for permanent employment based on performance
Position Type: Safety-sensitive

Schedule

• Training: Monday Friday, 8:00 AM 4:30 PM CST for the first eight weeks.
• Candidates must attend all training sessions and should not have planned time off during the training period.
• As part of the hiring process, we require all new hires to be on camera during meetings. This will include the training portion as well as any meetings with supervisor or team meetings.
• After Training: Assigned eight-hour shifts between 7:00 AM and 8:00 PM CST, Monday Friday.
• Rotating weekend and holiday coverage is required.
• Mandatory overtime or extended hours may be required during peak periods.

Position Overview
The Operations Representative II will support Medicare members, prescribers, and healthcare providers by processing coverage-related requests through phone and fax channels. Responsibilities include case setup, documentation review, outreach, issue resolution, and accurate processing in accordance with Medicare guidelines, CMS timelines, and internal quality standards.
This position requires strong attention to detail, professional communication skills, and the ability to navigate multiple systems in a regulated, productivity-driven environment.

Key Responsibilities

• Process prior authorizations, coverage determinations, medication-benefit exceptions, and appeals received by phone or fax.
• Accurately establish cases, review supporting documentation, and follow applicable work instructions.
• Conduct inbound and outbound calls with members, prescribers, and providers.
• Obtain missing information needed to complete coverage-related requests.
• Clearly and accurately document all case activities across multiple systems.
• Ensure cases are completed within CMS-mandated timelines and departmental quality standards.
• Review Medicare Part D and applicable Part B guidelines when processing requests.
• Identify errors, research processing issues, and take appropriate corrective action.
• Escalate complex cases or clinical questions to pharmacists or management.
• Maintain productivity, accuracy, confidentiality, and regulatory compliance.
• Participate in training, coaching, feedback, and continuous skill development.

Required Qualifications

• At least six months of customer service, healthcare, pharmacy, call-center, or related experience.
• Verifiable high school diploma or GED.
• Typing speed of at least 30 WPM.
• Strong written and verbal communication skills.
• Strong data-entry skills and attention to detail.
• Ability to navigate multiple Windows-based computer systems simultaneously.
• Ability to read and interpret work instructions, procedures, correspondence, and regulatory guidelines.
• Ability to work independently in a productivity-driven environment.
• Ability to sit, type, use a mouse, and remain focused for the full shift.
• Positive, professional, and team-oriented attitude.

Preferred Qualifications

• Call-center experience.
• Healthcare, pharmacy, PBM, Medicare, or managed-care experience.
• Experience handling confidential patient or member information.
• Experience using claims platforms, case-management systems, or internal databases.
• Previous remote-work experience.
• Pharmacy Technician Certification or related education is preferred but not required.

Remote-Work Requirements

• Dedicated, secure, quiet, and interruption-free home workspace.
• Wired internet connection; Wi-Fi and mobile hotspots are not permitted.
• Minimum internet speed of 25 Mbps download and 5 Mbps upload.
• Candidates must provide a screenshot of their internet speed test.
• Employees must remain on camera during training, supervisor meetings, and team meetings.
• Candidate's state and time zone must be included on the resume.