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Role Description

As an Eligibility Senior Representative, you play a critical role at the intersection of patients, providers, payers, and specialty pharmacy operations. You bring clarity to complex insurance benefits, remove barriers to care, and help ensure patients receive timely access to life-changing therapies. This role is ideal for someone who is confident, compassionate, and energized by making a meaningful difference every day.

• Drive timely referral processing by proactively identifying and resolving drug coverage and eligibility issues that impact turnaround time and patient access.
• Serve as a trusted liaison between internal teams and external partners, including payers, providers, and pharmaceutical manufacturers, to reduce client abrasion and improve outcomes.
• Independently resolve complex patient claims and eligibility issues using advanced knowledge of medical and pharmacy benefits.
• Ensure claims and referrals meet payer requirements by accurately validating codes, dates, authorizations, and coverage criteria.
• Perform complex medical and pharmacy benefit verifications, applying payer-specific rules and sound judgment to support reimbursable services.
• Communicate patient status clearly and confidently to internal and external stakeholders, providing expert guidance and next steps.
• Handle escalations with professionalism and discretion, applying deep understanding of policies while knowing when to escalate appropriately.
• Identify trends and root causes that affect patient access and operational performance, and contribute to continuous improvement efforts.
• Support team capability by coaching and guiding less experienced colleagues with patience and clarity.
• Adapt quickly in a dynamic environment, balancing priorities while maintaining accuracy, empathy, and accountability.

Qualifications

• High school diploma or GED.
• Minimum of 3 years of relevant professional experience, including at least 2 years in healthcare with hands-on experience in medical or pharmacy insurance benefits.
• Demonstrated experience in patient access, eligibility, benefits verification, or claims resolution.
• Strong working knowledge of healthcare insurance terminology, processes, and payer requirements.
• Proficiency with data entry and Microsoft Office tools.
• Excellent verbal communication skills, including confidence handling complex or challenging conversations.
• Proven ability to work independently, make sound decisions, and manage escalations with minimal supervision.
• Advanced problem-solving skills and the ability to collaborate across departments to deliver solutions.

Requirements

• Bachelor’s degree (preferred).
• Experience supporting specialty pharmacy or complex therapies (preferred).
• Strong knowledge of Express Scripts, Inc. (ESI) products and services (preferred).
• Experience training, mentoring, or coaching peers in processes and best practices (preferred).
• Demonstrated ability to identify process gaps and contribute to operational improvements (preferred).

Benefits

• If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.