Remote Coverage representative

Coverage Determination & Appeals Representative Location: Remote Pay Rate: $18.50/hour on W-2 Training: Monday–Friday, 9:00 AM–5:30 PM EST Work Schedule: Rotating schedule within Monday–Friday, 8:00 AM–8:00 PM EST, with weekend and holiday coverage as required Position Overview We are seeking a detail-oriented Coverage Determination & Appeals Representative to support the processing and triage of healthcare coverage determination and appeal requests. The primary responsibility of this position is to review incoming fax documentation, accurately enter and process information, and route cases to the appropriate queues for further review. The representative will also research reports, maintain complete and accurate case documentation, and escalate cases or issues to pharmacists or management when appropriate. Previous medical insurance experience is preferred but not required .

Key Responsibilities

Review incoming fax documentation for accuracy and completeness. Identify the appropriate workflow and route documents and cases to the correct processing queues. Perform data-entry activities related to coverage determination and appeal requests. Maintain complete, timely, and accurate case documentation. Research reports and available information as required to support case processing. Escalate appropriate cases or issues to Coverage Determination/Appeals pharmacists or management. Follow established procedures and processing requirements. Maintain current knowledge of relevant processes, regulations, and applicable clinical materials. Meet established accuracy, productivity, and quality expectations. Provide assistance or guidance in partnership with learning and development teams when needed. Participate in developmental discussions and incorporate feedback from supervisors. Support additional operational activities based on business needs.

Qualifications

Strong attention to detail and accuracy. Ability to review documents and correctly identify the appropriate workflow or processing queue. Strong data-entry and computer skills. Ability to follow established processes and procedures. Strong organizational and time-management skills. Ability to maintain accurate documentation. Good written and verbal communication skills. Ability to work independently in a remote environment. Ability to adapt to changing business needs and schedules. Previous medical insurance, healthcare, pharmacy benefits, prior authorization, coverage determination, or appeals experience is preferred but not required . Schedule Requirements Candidates must have flexibility regarding scheduling. Training Schedule: Monday–Friday, 9:00 AM–5:30 PM EST Regular Business Hours: Monday–Friday, 8:00 AM–8:00 PM EST The position requires schedule flexibility and may include rotating weekends, nights, and holiday coverage based on business needs.