Healthcare & Insurance Knowledge
Medicare Part D expertise
Understanding of insurance benefits & coverage
Knowledge of pharmacy benefits (PBM) processes
Familiarity with formulary and non-formulary drugs
Medical claims processing
Customer Service & Communication
Clear and compassionate communication with members
Ability to explain complex healthcare terms in simple language
Conflict resolution and de-escalation skills
Listening actively to member concerns and needs
Technical & Administrative Skills
Using CRM or healthcare systems to document interactions
Processing payments and test claims
Navigating pharmacy systems and claim overrides
Proficiency in call center tools and data entry
Analytical & Problem-Solving
Investigating claim denials and DUR (Drug Utilization Review) rejections
Identifying medication alternatives and tier differences
Coordinating prior authorizations and exception request
Service Coordination & Logistics
Scheduling and dispatching technicians
Placing work orders and appointments
Coordinating expedited service within 24 hours
Vendor/technician transfer management to meet service timelines
