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Medicare Authorization Representative
2 months ago
Client Services Specialist I
Location:
Fully remote
Job Overview:
The Client Services Specialist I is responsible for managing inbound communications from healthcare providers, pharmacies, and members, ensuring professional and courteous assistance throughout the prior authorization process.
This role requires maintaining comprehensive, timely, and precise documentation of all reviews conducted. The specialist will transfer clinical inquiries and escalations to the pharmacist team as necessary.
In addition to handling inbound calls, the specialist may perform outbound communications, review and process prior authorizations received through various channels, and respond to inquiries via departmental mailboxes, as directed by leadership.
The role involves close collaboration with healthcare providers to process prior authorization (PA) and drug benefit exception requests, adhering to Medicare Part D CMS Regulations. Specialists must apply information from multiple sources to the established plan criteria.
Responsibilities include researching and conducting outreach to providers for additional information to facilitate coverage requests and ensuring all necessary actions are taken to resolve cases. Phone assistance is crucial for initiating and resolving coverage requests, with escalation to Coverage Determinations and Appeals Learning Advocates and management as needed.
Compliance with CMS and departmental standards is mandatory at all times. The position requires flexibility in scheduling and additional cross-training to cover all lines of business.
Key Responsibilities:
- Utilizing various software systems to conduct Medicare appeals case reviews.
- Meeting government-mandated timelines and productivity standards.
- Communicating resolutions to beneficiaries or providers through direct communication and professional correspondence.
- Maintaining up-to-date knowledge of relevant Medicare guidance.
- Effectively managing work volume by handling inbound calls and requests with professionalism.
- Ensuring compliance with departmental, company, state, and federal requirements during information processing.
- Coordinating with internal teams regarding determination statuses and results.
- Identifying and escalating clinical inquiries to the pharmacist team as appropriate.
Qualifications:
- 0-3 years of experience in customer service or call center environments, managing a high volume of calls.
- Preferred experience in PBM/pharmaceutical sectors.
- At least two years of general business experience encompassing problem resolution, business writing, quality improvement, and customer service.
Skills Required:
- Prior Authorization knowledge.
- Understanding of Medicare and Medicaid processes.
Education:
High School diploma or GED
About US Tech Solutions:
US Tech Solutions is a global staffing firm offering a wide range of talent on-demand and comprehensive workforce solutions. We are committed to equal opportunity employment, ensuring all qualified applicants receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.
