Representative II, Operations

Position Summary 

Flexibility to work shifts between 7:00 AM – 8:00 PM Central Standard Time (CST) (Monday–Friday) and rotating weekend or holiday coverage as required by business needs. 

As a Representative II, Operations, you will support Medicare members, prescribers, and providers by processing coverage-related requests across both phone and fax (offline) channels. This role integrates responsibilities previously segmented by channel (phone vs. fax) and line of business (Medicare Part D and applicable Medicare Part B processes), reflecting the organization’s modularized training model in which colleagues progressively learn, practice, and apply end‑to‑end skills before fully transitioning to production work. 

In this role, you will be responsible for accurate case setup, review, outreach, documentation, and timely resolution of requests in accordance with Medicare guidelines, CMS-mandated timelines, and internal quality standards. You will demonstrate strong attention to detail, professional verbal and written communication skills, and the ability to problem-solve in a highly regulated, fast-paced environment. Work will be performed through a combination of inbound and outbound phone interactions and fax-based casework. 

This position is full-time, remote (Work at Home – Texas), non-exempt, and requires schedule flexibility based on business needs. 

Primary Duties and Responsibilities 

Case Intake, Review, and Processing (Phone & Fax) 

Outreach and Information Gathering 

• Conduct outbound calls to members and providers to obtain missing or additional information required to complete requests. 
• Communicate clearly, professionally, and empathetically while projecting a positive business image. 

Documentation, Accuracy, and Compliance 

• Provide clear, concise, and accurate documentation of all case activity across systems. 
• Ensure all cases are properly closed and meet CMS-mandated timelines, department productivity expectations, and quality standards. 
• Identify and research issues in the overall process and correct errors when identified. 

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Escalation and Collaboration 

• Raise complex issues or clinical questions to Coverage/Organization Determination Clinical Pharmacists or management as appropriate. 
• Collaborate with peers, trainers, and leaders while progressing through modular training and skill expansion. 

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Continuous Learning and Development 

• Acquire and maintain working knowledge of evolving work instructions, systems, and Medicare guidance (Part D and applicable Part B processes). 
• Participate in coaching, feedback, and development discussions with direct leadership. 

Required Qualifications

Preferred Qualifications

• Call center experience. 
• Experience in a PBM, managed care, or healthcare environment.
• Strong verbal and written communication skills. 
• Ability to problem-solve and manage multiple concrete variables in standardized situations. 
• Experience handling confidential patient or member information. 
• Familiarity with multi-system workflows (e.g., claims platforms, case management systems, internal databases). 
• Pharmacy Technician Certification (CPhT) or related education. 

​ Education

High School Diploma or equivalent GED