Representative II, Operations

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

About the role

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.

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

Responsibilities

• 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.
• 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.
• 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.
• 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.
• 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.

Requirements

• 6 plus months customer service, healthcare, pharmacy, call center, or related experience.
• Typing ability of 30 WPM or greater.
• High School Diploma or equivalent GED.

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.

Pay

The typical pay range for this role is $17.00 - $31.30 per hour. This pay range represents the base hourly rate for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Schedule

• Full-time, 40 hours per week.
• Shifts between 7:00 AM – 8:00 PM Central Standard Time (CST), Monday–Friday.
• Rotating weekend or holiday coverage as required by business needs.

Benefits

This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. Benefits include:

• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources, based on eligibility.