In this role, Coverage Determination Representative I, contractors will be responsible for:
· Utilizing multiple software systems to create Medicare Prior Authorization case reviews
· Meeting or exceeding government mandated timelines
· Complying with turnaround time, productivity, and quality standards
· Acquiring and maintaining basic knowledge of relevant and changing Med D guidance

Duties
Responsibilities
1. Review Fax documents appropriately and forward to appropriate queues
2.Update and maintain knowledge of relevant process, regulation and clinical material.
3.Provide assistance or guidance in partnership with learning and innovation when needed
4.Participate in developmental discussions receiving feedback with Supervisor
Experience
previous medical insurance background preferred but not required

The Coverage Determination/Appeals Service Representative I is responsible for working and triaging in the data entry related fax queues. The Representative I’s primary responsibilities will be to review each document with accuracy and place the case in the proper queues. Further responsibilities include researching reports, maintaining complete, timely and accurate documentation of Coverage Determination/Appeal requests and escalating issues to the Coverage Determination/Appeal pharmacists or management staff as needed.

Education
High School diploma or GED

Position will require schedule flexibility including rotations through Nights, Weekends and Holiday Coverage. All other duties are required to meet business needs.
? Training hours Mon- Fri 9-5:30pm EST
? Working hours with rotating weekends Mon-Fri 8-8pm EST

Notes:
Hybrid position, required to report onsite for manual staffing duties 2-3 onsite days with weekends shift reporting on site Saturday and Sunday.

safety sensitive
Onsite as needed