Rep I, Clinical Services/Clinical Support Representative

4 weeks ago

Woonsocket, United States VIVA USA Inc Remote Work Freelance Full time $16 - $18
Rep I, Clinical Services
Remote job only
12 months contract
Woonsocket, RI, 02895

Note:
Assigned shifts vary from 7AM-8PM CT. Training hours 8AM-430PM CT
Fully remote (never coming onsite)

Description:
The Rep I, Clinical Services takes in-bound calls from providers, pharmacies, members, etc providing professional and courteous phone assistance to all callers through the criteria based prior authorization process. Maintains complete, timely and accurate documentation of reviews. Transfers all clinical questions, escalations and judgement calls to the pharmacist team.

The Rep I, Clinical Services will also assist with other duties as needed to include but not limited to: outbound calls, reviewing and processing Prior Auth’s received via fax and ePA, monitoring and responding to inquiries via department mailboxes and other duties as assigned by the leadership team.

Position Summary:
The client CD Representative II will work closely with providers to process prior authorization (PA), and drug benefit exception requests on behalf of client as the client and in accordance with Medicare Part D CMS Regulations. Must apply information [provided through multiple channels] to the plan criteria defined through work instruction. Research and conduct outreach via phone to requesting providers to obtain additional information to process coverage requests and complete all necessary actions to close cases. Responsible for research and correction of any issues found in the overall process. Phone assistance is required to initiate and/or resolve coverage requests. Escalate issues to Coverage Determinations and Appeals clinical pharmacists and management team as needed. Must maintain compliance at all times with CMS and department standards. Position requires schedule flexibility including rotations through nights, weekend and holiday coverage.

Duties:
  • Customer service focus. Basic experience in MSWord and MSExcel. 
  • Familiar with medical terminology and knowledge of medical coding. 
  • Ability to read and interpret billing documents. The position also requires an extensive amount of data entry work.

Experience:
  • 2 years experience.
  • Strong Attention to detail.
  • Excellent verbal and written communication and interpersonal skills w/ ability to maintain patient confidentiality.
  • Proficient computer skills and the ability to navigate in a Windows based environment.
  • Ability to follow directions, and adapt in dynamic work environment; ability to adapt to change and remain flexible.
  • Ability to work in a high pressure, time sensitive environment.
  • Project a professional business image, through phone interaction as well as internal communications.
  • Demonstrated problem-solving ability and attention to detail.
  • Demonstrated sense of urgency with assignments.
  • Strong organizational skills.
  • Strong telephone skills.
  • Ability to read and understand pharmacy/medical terminology.
  • Ability to read, analyze and interpret general business correspondence, technical procedures and governmental regulations.
  • Ability to identify and solve practical problems and deal with a variety of concrete variables in standardized situations. Ability to perform basic mathematic calculations maybe required.
  • Ability to interpret a variety of work instructions provided through a variety of mediums.
  • Ability to anticipate needs and resolve issues with urgency.
  • Ability to consistently meet quality and production standards.
  • Displays confidence in the ability to learn complex material.
  • Demonstrates intellectual curiosity through inquiries to ensure deep understanding of the business and deliver accurate results.

Education:
  • High School Diploma or GED required. 
  • Associates degree in Business, Accounting or equivalent work experience preferred.

This is a safety role.

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