Senior Eligibility Representative
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Job Description
Eligibility Senior Representative reviewing benefits and resolving coverage issues for Evernorth Health Services’ specialty-pharmacy referrals. Supporting patients, providers, payers, and internal partners to improve therapy access and continuity.
Responsibilities:
- Conduct medical and pharmacy benefit investigations to confirm eligibility, coverage, payer requirements, and patient financial responsibility
- Verify insurance eligibility, benefit details, coverage limitations, and documentation requirements for timely referral processing
- Identify prior authorization, appeal, step therapy, quantity limit, and other utilization management requirements affecting therapy access
- Research and resolve complex reimbursement, eligibility, and coverage issues with payers, providers, patients, and internal partners
- Educate patients on copay, coinsurance, and financial responsibility
- Assist with enrollment in available copay assistance, manufacturer support, and patient assistance programs
- Document referral activity accurately in company systems and follow departmental procedures for service, quality, and compliance
- Monitor assigned referrals, manage escalations, and help reduce delays in therapy initiation and treatment continuity
Requirements:
- High school diploma or equivalent
- Minimum of 1 year of experience in healthcare, specialty pharmacy, patient access, reimbursement, insurance verification, or a related field
- Knowledge of insurance eligibility, coverage requirements, reimbursement processes, prior authorization, or payer requirements
- Strong attention to detail and problem-solving skills
- Ability to manage multiple priorities while maintaining accuracy
- Clear verbal and written communication skills
- Ability to explain coverage and financial information professionally
- Ability to use computer systems and accurately document work
- Experience conducting medical and pharmacy benefit investigations preferred
- Experience supporting specialty pharmacy, patient access, reimbursement, or new referral intake workflows preferred
- Experience with complex medical and pharmacy benefit structures or payer requirements preferred
- Knowledge of specialty drug reimbursement, copay assistance, manufacturer support programs, or patient assistance programs preferred
- For home work, cable broadband or fiber optic internet with at least 10Mbps download/5Mbps upload
Benefits:
- Copay assistance, manufacturer support programs, and patient assistance programs, as applicable
- Remote work arrangement
- Tobacco-free policy
- Reasonable accommodation support for the online application process
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