Remote Coverage & Prior Authorization Specialist

A-Line Staffing Solutions; Lewisville (TX); On-site; USD 23,000 - 32,000; Full time

Job summary

A-Line Staffing Solutions is seeking a Remote Coverage Determination Specialist to support PBM and health plan coverage determinations. You will help members and providers move requests to resolution in a fast-paced queue.

This role requires Medicare Part D, prior authorizations, and payer documentation knowledge. Work From Home in the United States, with a Monday–Friday schedule and an afternoon training block.

Qualifications

• High School Diploma/GED (or equivalent work experience).
• 1+ year experience in PBM, health plan operations, coverage determinations, Medicare Part D, prior authorization, pharmacy benefits, or appeals/grievances preferred
• Strong data entry, attention to detail, and ability to manage high-volume casework/queues
• Professional written and verbal communication; comfortable handling member/provider conversations
• Familiarity with medical/pharmacy terminology, payer policies, and documentation requirements preferred
• Dedicated, quiet workspace and hardwired broadband internet (no WiFi/hotspot)

Responsibilities

• Process coverage determination and prior authorization-related requests using written work instructions and program guidelines
• Conduct benefit investigations and coverage research (Commercial, Medicare, Medicaid; strong emphasis on Medicare/PBM workflows)
• Identify and initiate PA, step therapy, and exception requirements; support appeals workflows when needed
• Place and receive inbound/outbound calls with providers/payers; maintain strong call quality and professional communication
• Gather missing information and drive timely follow-up to meet required turnaround times
• Document all actions clearly and accurately across systems (case platforms, payer portals, email, trackers/spreadsheets)
• Escalate complex cases appropriately and maintain compliance with HIPAA/PHI standards

Skills

Data entry

Attention to detail

Professional communication

Member/provider conversations

Medical terminology familiarity

Education

High School Diploma/GED

Job description

A-Line Staffing Solutions is seeking a Remote Coverage Determination Specialist to support PBM and health plan coverage determinations. You will help members and providers move requests to resolution in a fast-paced queue.

This role requires Medicare Part D, prior authorizations, and payer documentation knowledge. Work From Home in the United States, with a Monday–Friday schedule and an afternoon training block.