Coverage Determination Representative - Remote {174793}

Coverage Determination Representative (Remote/WFH)

Location: Remote (anywhere in the U.S.)
Pay: $20.28/hr (W2)
Type: 48-week contract | Full-time (40 hrs/week)

Overview

We’re hiring Coverage Determination Representatives to support Medicare members, prescribers, and providers by processing coverage-related requests across phone and fax/offline channels. You’ll complete accurate case setup, review documentation, conduct outreach for missing information, and ensure requests are handled within CMS/Medicare guidelines and required timelines.

Schedule (CST)

• Training (first 8 weeks): Monday–Friday 8:00 AM – 4:30 PM CST (attendance is critical; no planned time off strongly preferred)
• After training: Rotating 8-hour shifts between 7:00 AM – 8:00 PM CST, Monday–Friday
• Rotating weekends/holidays may be required
• Overtime may be required during peak periods

Key Responsibilities

• Process coverage-related requests (e.g., coverage determinations, exceptions, appeals) via phone and fax
• Set up cases, review documentation, and follow work instructions for timely processing
• Make outbound calls to members/providers to gather missing details
• Document all case activity clearly and accurately across systems
• Meet productivity and quality standards; escalate complex issues appropriately
• Learn and apply evolving workflows through coaching and modular training

Required Qualifications

• High School Diploma or GED (verifiable)
• 6+ months experience in customer service, healthcare, pharmacy, call center, or related work
• Comfortable working in a fast-paced, highly regulated environment
• Ability to navigate multiple systems/screens; strong data entry skills
• Typing 30 WPM+
• Ability to sit and work at a computer for the full shift with minimal interruptions

Work-from-Home Requirements (Must Have)

• Dedicated, quiet, secure workspace (no interruptions)
• Wired internet connection (no Wi-Fi/hotspots)
• Internet speed: 25 Mbps download / 5 Mbps upload minimum
• Camera-on required during training and meetings

Preferred

• Pharmacy, medical, PBM, managed care, or healthcare environment experience
• Prior work-from-home experience
• Experience handling confidential member/patient information

Interested?

Reply with your resume and include:

1. Your state + time zone
2. A Speedtest screenshot (from Speedtest.net) showing your internet speeds
3. Confirmation you can attend the 8-week training schedule (8:00 AM–4:30 PM CST) and work rotating shifts/weekends after training