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Coverage Determination Specialist
hace 1 mes
What you’ll do
In a few words…
Abarca is igniting a revolution in healthcare. We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning…
Providing high quality services to clients and beneficiaries is at the core of what we do every day The PBM Operations & Services team is the very heart of Abarca and meets that standard by running services from medication therapy management programs, price eligibility, configurations, and beneficiary services to government services and beyond. Within Coverage Determination, our teams handle case determination, triaging calls from physicians and pharmacies among other support items.
As a Coverage Determination Specialist, you will be responsible to create and evaluate coverage determinations for our clients. You will communicate with pharmacists, beneficiaries, and doctors regarding pending coverage determinations for our clients beneficiaries, applying clinical knowledge in each coverage determination case. You must comply with all federal rules and regulations, and client contracts and have disposition to give an extra mile in every coverage determination case.
The fundamentals for the job…
- Review and Respond to all Coverage Determination (CD) requests, and claims pending to be adjudicated for Medicare and/or Commercial-plan beneficiaries, always in an accurate and timely manner.
- Receive calls from pharmacies, physicians and members in relation to status of CD requests.
- Initiate calls to physicians, pharmacy and members when additional information is required for processing and adjudicating a CD request.
- Generate calls, faxes and/or letters to pharmacies, physicians and members in reference to coverage determination requests’ resolutions.
- Document Coverage Determination (CD) request inquiries, issues, status and resolution in accordance with federal and department / company policies and guidelines.
- Review faxes and emails and create new cases for Medicare/Medicaid or Commercial plans.
- Support Pharmacists in gathering additional information to support the decision of making an exception (formulary, non-formulary or other requests).
- Ensure Medicare & Medicaid Services (CMS) Compliance or other regulating entities related to coverage determinations.
- Complete other Coverage Determination related tasks, as assigned.
What we expect of you:
The bold requirements…
- Associate’s Degree in Pharmacy Technician. (In lieu of a degree, equivalent, relevant work experience may be considered.)
- 3+ years of experience in customer service.
- Experience with Microsoft Office tools (Outlook, Excel, Power Point, and Word).
- Available to work rotating shifts, including nights, weekends, and holidays.
- Excellent oral and written communication skills. Fluency in English and Spanish is required.
- We are proud to offer a flexible hybrid work model which will require certain on-site workdays (Puerto Rico Location Only)
- This position requires availability to work in a specified time zone or working schedule, accommodating the business needs of our clients and team members.
- This position may require availability for on-call hours, including evenings, weekends, and holidays, to promptly address emergent issues or provide necessary support as dictated by operational demands (if applicable).
Nice to have…
- Certified Pharmacy Technician License is preferred.
- Experience in healthcare or pharmacy setting.
Physical requirements…
- Must be able to access and navigate each department at the organization’s facilities.
- Sedentary work that primarily involves sitting/standing.
At Abarca we value and celebrate diversity. Diversity, equity, inclusion, and belonging are guiding principles of Abarca and ensure Abarca’s workforce reflects the communities it serves. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.
Abarca Health LLC is an equal employment opportunity employer and participates in E-Verify. “Abarca Health LLC does not sponsor employment visas at this time”
The above description is not intended to limit the scope of the job or to exclude other duties not mentioned. It is not a final set of specifications for the position. It’s simply meant to give readers an idea of what the role entails.
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