Representative, Customer Service II

Your Future Evolves Here Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture. What You'll Be Doing: Our Representative, Customer Service II candidates can anticipate a role that plays a pivotal part in ensuring client satisfaction through the process of receiving and reviewing prescription and medical drug prior authorization (PA) requests from providers and members via telephone, fax, email, and web-enabled submissions. Candidates will provide value through efficient organization, communication, and documentation. Joining our team offers the satisfaction of contributing to an engaged team with a streamlined process and being a key link in our commitment to delivering exceptional service and better health outcomes. Collaboration Opportunities: Representatives will be working with and providing support to health plans, providers, support staff and Clinicians. Leadership rewards and regularly recognizes employees for performance in an environment that challenges while providing clear direction and support to foster success in the role. What You'll Be Doing: Answer and manage inbound pharmacy inquiries from members, pharmacy and/or provider contacts for pharmacy benefit information, clinical determinations, and program information. Ask appropriate questions and listen actively to identify specific questions or issues to provide appropriate response and type of assistance the customer needs while documenting relevant information in a clear and concise manner in computer systems. Communicate and partner with customers tactfully and empathetically to resolve issues, using clear language translating healthcare-related jargon and complex processes into simple, step-by-step instructions customers can comprehend and act upon. Handle and process customer complaints/ grievances while applying appropriate conflict management skills to de-escalate potentially stressful situations. Coordinate and triage all pharmacy inquiries (i.e. phone, fax, correspondence, electronic media) and resolve all customer issues; ensuring accurate information is provided. Function as liaison and subject matter expert related to client PBM systems and processes. Specifically related to drug utilization management, drug prior authorization and pharmacy claim adjudication. Obtain verbal prior authorization requests from member and/or prescribers while compiling and documenting accurate conversation details. Assists with the Prior Authorization process Always maintain the confidentiality of protected patient medical information. Meet the performance goals established for the position in the areas of efficiency, accuracy, quality, member satisfaction and attendance. Adhere to all applicable department, organization and/or regulatory policies and procedures. Read, comprehend, and verbalize processes and procedures of the organization and of health insurance coverage. Navigate across multiple computer systems to respond to questions from external and/or internal partners. Compile and document accurate conversations with member, pharmacy, and/or provider. Notify physicians, providers, and members of coverage determination request decisions. Ability to adapt to a changing environment including scheduling flexibility with the ability to work evening and weekend hours, as necessary. Qualifications Required and Preferred: High School Diploma / GED is required. Certified Pharmacy Technician (CPhT) is preferred. 2+ years of practice experience in health plan, PBM, pharmacy or health care practice with Call Center experience is preferred. Experience working in a pharmacy related setting is preferred. Strong written and oral communication skills along with PC skills including MS Word is required. Strong attention to detail is required. Compassion when dealing with patients and providers is required. Bilingual in Spanish is preferred. Ability to work independently and solve problems in a fast-paced, quickly changing environment is required. Strong organizational and prioritization skills is required. Strong customer focus with commitment to providing excellent customer service is required. Committed to a team-oriented work environment is required. Technical Requirements: We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations. Evolent is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status. If you need reasonable accommodation to access the information provided on this website, please contact for further assistance. The expected base salary/wage range for this position is $19/hr. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts. Don't see the dream job you are looking for? Drop off your contact information and resume and we will reach out to you if we find the perfect fit For more insights about Evolent Health, click on Life At Evolent ( to learn more

Created: 2024-11-02