Coverage Determination Representative I

Job overview

The Coverage Determination Representative I role is remote, with the listing location in Woonsocket, RI. Compensation is listed as $18.00–$18.98 per hour. Training is Monday–Friday, 9:00 AM–5:30 PM EST for the first eight weeks; afterward, assigned eight-hour shifts rotate within 8:00 AM–8:00 PM EST, with rotating weekends. The role supports Medicare prior authorization case reviews. The representative reviews and routes fax documents, enters data across multiple systems, and maintains accurate, timely documentation of coverage determination and appeal requests. The work helps meet government timelines and productivity and quality standards, with issues escalated to pharmacists or management as needed.

What you'll do

• Use multiple software systems to create Medicare prior authorization case reviews
• meet government-mandated timelines and turnaround, productivity, and quality standards
• review fax documents and forward them to appropriate queues
• maintain knowledge of relevant processes, regulations, and clinical material
• research reports
• maintain complete, timely, and accurate documentation
• escalate issues to pharmacists or management as needed
• provide assistance or guidance in partnership with learning and innovation when needed
• participate in developmental discussions and receive supervisor feedback.

What we're looking for

Skills & competencies

coverage determination representative

medicare prior authorization

appeals

fax queue review

data entry

remote

woonsocket ri

rotating weekends

rotating shifts

8:00 am–8:00 pm est

$18.00–$18.98/hr

high school diploma or ged

integrated resources

Work arrangement

• Weekend coverage required

Why this role

Remote role requiring a dedicated quiet workspace and wired internet with at least 25 Mbps download and 5 Mbps upload; high school diploma or GED; pharmacy or medical background preferred but not required; possible outbound calls.

About the employer

Integrated Resources, Inc is hiring for this role. Industry: Direct Health and Medical Insurance Carriers. Sector: 52.