medicare operations representative.

As an Medicare Operations Representative, you will process Medicare coverage requests (such as prior authorizations, drug exceptions, and appeals) through both phone and fax channels. Working in a fast-paced, highly regulated environment, you will handle case setup, review, member/provider outreach, and documentation to ensure timely resolutions.

This role uses a progressive, hands-on training model where you will learn and apply end-to-end skills across phone and offline workflows, supporting both Medicare Part D and applicable Part B processes. ***Candidates MUST be flexible to work between 7:00 a.m. - 8:00 p.m. CST and rotating weekends***



salary: $20 - $20.28 per hour
shift: First
work hours: 7 AM - 8 PM
education: High School

Responsibilities

• Process Requests: Accurately set up, review, and process incoming coverage determinations, prior authorizations, exceptions, and appeals received via phone and fax.
• Conduct Outreach: Make outbound calls to members, prescribers, and providers to collect missing information needed to resolve cases.
• Maintain Compliance: Ensure all cases meet CMS-mandated timelines, department quality standards, and internal productivity goals.
• Document Work: Record clear, concise, and accurate details of all case interactions and updates across multiple computer systems.
• Escalate Complex Cases: Route complex or clinical questions to Clinical Pharmacists or leadership when appropriate.
• Continuous Learning: Complete modular training to expand your skill set and stay current on evolving Medicare guidelines and software tools.

The essential functions of this role include:

working weekends

Skills

Medicare/Medicaid

Active Listening

Patient Support

Data Entry (1 year of experience is required)

Basic Computer Skills

Customer Service (2 years of experience is required)

Call Center Support (2 years of experience is required)

Healthcare (2 years of experience is required)

Qualifications

Years of experience: 2 years

Experience level: Experienced

Randstad is a world leader in matching great people with great companies. Our experienced agents will listen carefully to your employment needs and then work diligently to match your skills and qualifications to the right job and company. Whether you're looking for temporary, temporary-to-permanent or permanent opportunities, no one works harder for you than Randstad.

Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.

At Randstad, we welcome people of all abilities and want to ensure that our hiring and interview process meets the needs of all applicants. If you require a reasonable accommodation to make your application or interview experience a great one, please contact HRsupport@randstadusa.com.

Pay offered to a successful candidate will be based on several factors including the candidate's education, work experience, work location, specific job duties, certifications, etc. In addition, Randstad offers a comprehensive benefits package, including: medical, prescription, dental, vision, AD&D, and life insurance offerings, short-term disability, and a 401K plan (all benefits are based on eligibility).

This posting is open for thirty (30) days.

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.