Call Center Representative (Healthcare/Pharmacy)

Summary/Objective

The Patient Copay Support Representative serves as a frontline contact for patients, caregivers, providers, pharmacies, and advocates who need assistance with prescription insurance, pharmacy benefit issues, out-of-pocket costs, and copay support services. Working within established program guidelines, the representative explains benefit and copay information in clear language, supports enrollment and medication access activities, researches common pharmacy claim issues, and documents each interaction accurately. This role requires empathy, attention to detail, strong customer service, and the ability to manage a high-volume contact center environment while appropriately escalating clinical, legal, or other complex matters outside the scope of the position.

Essential Job Functions

Patient Support & Copay Program Services

• Respond to a high volume of inbound contacts from patients, caregivers, providers, pharmacies, and advocates regarding prescription costs, pharmacy processing issues, available access programs, enrollment, and eligibility screening.
• Explain common healthcare and pharmacy benefit concepts in plain language, including copays, deductibles, coinsurance, out-of-pocket maximums, coverage limitations, and accumulator/maximizer program impacts.
• Screen patients for manufacturer copay card and financial assistance program eligibility using established criteria and support appropriate enrollment, activation, and referral workflows.
• Assist with copay program questions, including enrollment status, card balance, annual limits, expiration, activation, and other program-related inquiries.
• Provide empathetic, high-touch customer service and help patients understand next steps while maintaining appropriate professional boundaries.

Insurance, Benefit Verification & Claim Support

• Contact payers and/or pharmacy benefit managers, as applicable, to obtain and document benefit information, coverage details, and patient responsibility information, including participation in accumulator or maximizer programs.
• Read and interpret explanation of benefits (EOB) information, prescription claim responses, patient responsibility amounts, insurance benefit information, and common pharmacy rejection messages within the scope of the assigned program.
• Research and resolve common rejected pharmacy claims using established procedures, including eligibility issues, refill-too-soon rejections, coordination-of-benefits issues, prior authorization requirements, plan limitations, and other third-party billing rejections.
• Coordinate with payers, pharmacy benefit managers, patients, pharmacies, providers, and internal teams to obtain information and move issues toward appropriate resolution.
• Monitor and communicate the status of pending prior authorizations, identify outstanding requirements, and coordinate with the appropriate internal team, payer, pharmacy, or provider office. This role does not make clinical determinations.

Documentation, Compliance & Escalation

• Maintain accurate patient and insurance information, including policy identification numbers, group numbers, BIN information, contact details, and other required data elements.
• Document patient interactions, benefit findings, claim activity, enrollment activity, commitments, and next steps accurately and chronologically in the designated CRM or case management system.
• Verify patient identity and follow all applicable HIPAA, privacy, information security, and client/program verification requirements before discussing protected information.
• Route clinical questions, legal inquiries, complaints, and escalated issues to the appropriate supervisor, Tier-2 resource, or specialized internal team using established escalation paths.
• Follow Omega and client policies, procedures, scripts, quality standards, and security requirements while handling protected health information and other confidential data.

Key Success Indicators/Attributes

• Consistently meets established program expectations for first-contact resolution, average handle time, quality assurance, documentation accuracy, attendance, and schedule adherence.
• Delivers professional, empathetic, and patient-centered service, including during emotionally sensitive or high-stress interactions.
• Demonstrates strong interpersonal, verbal, and written communication skills with patients, caregivers, physicians, nurses, pharmacists, pharmacies, payers, and internal partners.
• Maintains accuracy and attention to detail while navigating multiple systems, screens, workflows, and concurrent tasks.
• Demonstrates agility and willingness to work in a consistently evolving contact center environment and adapt to changes in programs, procedures, technology, and client requirements.
• Uses sound judgment to follow established procedures, recognize issues outside the role's scope, and escalate appropriately.
• Maintains confidentiality, professionalism, reliability, and a strong commitment to customer service.

Supervisory Responsibility

None required.

Work Environment

This role operates in a professional contact center environment, which may be onsite, hybrid, or remote depending on the assigned program and client requirements. The position routinely uses a computer, telephone/headset, dual monitors, and multiple web-based or client applications and requires sustained attention to voice and data-entry work.

Physical Demands

The physical demands are representative of those required to perform the essential functions of this role.

The position primarily involves sitting, speaking, hearing, typing, and viewing a computer screen for extended periods, with occasional standing and walking.

Position Type/Expected Hours of Work

This is a full-time, non-exempt position. Specific work hours, time zone coverage, weekend or holiday requirements, and onsite, hybrid, or remote expectations are based on the assigned program and client requirements. Flexibility may be required to support operational needs.

Travel

Regular travel is not expected. Any travel requirement will be based on business or program needs.

Required Education and Experience

• High School Diploma or GED required.
• Working knowledge of U.S. healthcare insurance concepts, including copays, deductibles, coinsurance, and out-of-pocket maximums, along with general pharmacy and healthcare terminology.