Coverage Determination Representative II

Integrated Resources, Inc.; United States; Remote; USD 10,000 - 60,000; Full time

Job summary

A healthcare services provider seeks a Coverage Determination Representative II to manage Medicare prior authorization requests. Responsibilities include reviewing requests, communicating with providers, and ensuring compliance with regulations. The ideal candidate will have experience in a clinical review or pharmacy setting, strong attention to detail, and proficient computer skills. This remote position requires a dedicated workspace and a wired internet connection.

Qualifications

• Minimum 2 years of relevant experience preferred.
• Proficient computer skills with ability to multitask.
• Ability to read and interpret pharmacy/medical terminology.

Responsibilities

• Review and complete Medicare prior authorization requests.
• Communicate with providers via phone to obtain additional info.
• Escalate complex cases to pharmacists and management.

Skills

Attention to detail

Problem-solving

Verbal communication

Written communication

Computer skills

Education

High School Diploma or GED

Associates degree in Business or Accounting

Job description

Job Title: Coverage Determination Representative II
Location: Remote, RI 27607
Duration: 6 Months+ (Contract With possibility of Extension)
Pay Rate: $20.27/hr. on W2

Important Hiring Information:

• Safety Sensitive Role
• Start Date: 10/20
• Offer Acceptance By: 9/19
• Last Date to Clear: 10/10
• Offer Extended By: 9/15
• Shift: Rotating 8-hour shifts between 8 AM – 8 PM EST, including rotating weekends
• Training: Mandatory 8 weeks, Mon-Fri, 9 AM – 5:30 PM EST (no planned time off)
• Work Location: 100% Remote, must have a dedicated quiet workspace
• Internet: Wired connection only, minimum 25 Mbps download and 5 Mbps upload (include screenshot of speedtest.net results on resume)
• Technology: Must have experience working with multiple software platforms and dual monitors
• Camera: Must be on camera for all training and meetings
• Resume Requirements: Include state and time zone at the top; internet speed test screenshot; Certification/License NOT required

Candidate Pre-Submission Questions — Please Confirm:

• Do you have any conflicts with the mandatory training schedule (M-F, 9 AM – 5:30 PM EST for 8 weeks)?
• Are you able to work assigned rotating shifts (8 AM – 8 PM EST) including weekends?
• Do you have a private, quiet workspace with a wired internet connection that meets the speed requirements? Please provide your internet provider and speed.
• Are you able to sit and focus without interruptions for the entire shift?
• Do you have experience with data entry and navigating multiple computer applications?
• Do you have a pharmacy or medical background? (Preferred but not required)
• Are you able to work independently in a productivity-driven role?
• Do you consider yourself an engaged and positive team player?

Position Overview:

• Review and complete Medicare prior authorization and drug benefit exception requests per CMS regulations.
• Communicate with providers via phone and professional correspondence to obtain additional info.
• Escalate complex cases to pharmacists and management.
• Comply with strict turnaround times, productivity, and quality standards.
• Maintain confidentiality and professional communication at all times.

Required Experience & Skills:

• Minimum 2 years of relevant experience (prior authorization, clinical review, or pharmacy/medical-related preferred)
• Strong attention to detail and problem-solving skills
• Excellent verbal and written communication
• Proficient computer skills with ability to multitask
• Ability to work under pressure and meet deadlines
• Ability to read and interpret pharmacy/medical terminology and government regulations

Education:

• High School Diploma or GED required
• Associates degree in Business, Accounting, or related field preferred (or equivalent work experience)