IR
Representative II
Integrated Resources, Inc
🇺🇸 United States
On-site
3 weeks ago
- CMS
- Windows
3 weeks ago
Not enough detail in this posting to match
Location : Woonsocket RI 02895
Duration :11/02/2026 to 10/03/2027
Pay $20.00 to $28.28
Duties:
Case Intake, Review, and Processing (Phone & Fax)
• Process incoming coverage-related requests (e.g., prior authorizations, coverage determinations, drug benefit exceptions, appeals) via phone and fax from members and prescribers.
• Accurately set up cases, review documentation, and apply work instructions to ensure correct and timely processing.
• Read, analyze, and interpret business correspondence, technical procedures, and Medicare regulations to support decision-making.
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.
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.
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.
Experience:
• Experience:
o Minimum of 6+ months customer service, healthcare, pharmacy, call center, or related experience.
• Education:
o Verifiable High School Diploma or GED required.
• Skills and Abilities:
o Strong verbal and written communication skills.
o Ability to problem-solve and manage multiple concrete variables in standardized situations.
o Proficiency navigating multiple computer systems simultaneously in a Windows-based environment.
o Ability to interpret work instructions delivered through multiple systems and formats.
o Ability to perform basic mathematical calculations.
o Typing ability of 30 WPM or greater.
Preferred Qualifications
• Call center experience.
• Experience in a PBM, managed care, or healthcare environment.
• 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. 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.
Representative II · Integrated Resources, Inc