Customer Service Rep II - Non-Exempt

About the Role

As a Prior Authorization Representative, you will verify prior authorization requirements and obtain authorization when needed. You will work directly with physician offices and payers to facilitate patient access to various therapies, ensuring patient insurance coverage and benefits, identifying requirements for prior approval, and submitting for authorization. You will also assist with appealing prior authorization denials, retro authorization, or other special cases.

Responsibilities

• Validates patient insurance coverage and communicates any issues with benefits or coverage to the appropriate managers.
• Checks requirements for prior authorization and initiates the process as required.
• Coordinates required paperwork, clinical notes, and forms for submission to support authorization requests.
• Follows up frequently to ensure visibility on authorization status throughout the approval process.
• Represents the company to external and internal customers, answering product-related questions and resolving issues (e.g., tracing lost shipments, interpreting customer orders).
• May manage web-based ordering, handle customer credits, process returns, address quality assurance complaints, and manage pricing adjustments.
• May approve stock allocation in short supply, special price quotations, bids, pricing allowances, deductions, and adjustments.
• May manage inventories at customer facilities using EDI (electronic data interchange), forecasting, replenishment, and inventory systems to maximize service levels.

Requirements

• Basic knowledge of payer payment processes with detailed knowledge of the payer prior authorization process.
• Familiarity with ICD-9/10 and CPT codes, with expert knowledge of a subset of client therapy codes.
• Superior customer service and communication skills for interacting with physicians, sales representatives, payer representatives, utilization reviewers, and other stakeholders.
• Advanced Microsoft Excel skills.
• Ability to learn and use multiple CRM software programs as needed.
• Strong organizational skills with the ability to handle multiple inquiries simultaneously and critical problem-solving skills with high attention to detail.

Qualifications

Requires full job knowledge of systems and procedures obtained through prior work experience or education. A minimum of 2 years of relevant experience is required.

Differentiating Factors

• Autonomy: Works as an established and productive individual contributor on clerical and administrative assignments, applying prior experience under moderate supervision.
• Organizational Impact: Delivers on day-to-day objectives with direct impact on results for the job area, including moderate scheduling or customer satisfaction implications.
• Innovation and Complexity: Checks and makes minor adjustments to work methods to solve routine problems within existing processes and systems. May highlight areas of concern and propose solutions.
• Communication and Influence: Communicates with internal contacts within and outside the immediate team, obtaining and providing information requiring explanation or interpretation.
• Leadership and Talent Management: May provide guidance and assistance to new or entry-level employees.