Bilingual Lead, Coverage Determination & Pharmacy Benefits

Abarca Health LLC.; San Juan, Northern (PR, KY); Hybrid; USD 70,000 - 90,000; Full time

Job summary

Abarca Health LLC in San Juan, Puerto Rico, is seeking a Supervisor, Coverage Determination to oversee and coach the Coverage Determination team, ensuring cases are resolved accurately and on time across Commercial and Medicare plans. You will mentor staff, monitor KPI/quality, coordinate CMS compliance, assist with requests, and support training on CMS changes.

This role requires a Pharmacy Technician license, 6+ years in coverage determination, and Spanish-English fluency.

Qualifications

• Must have Pharmacy Technician license (active).
• 6+ years of experience managing coverage determination processes, including 1+ years leading a team.
• Experience in insurance, pharmacy, or healthcare industries.
• Spanish and English bilingual proficiency required.
• Excellent oral and written communication skills.

Responsibilities

• Coach and support the Coverage Determination team to ensure timely, high-quality case resolution.
• Assist CD Specialists with coverage determination requests and claims pending adjudication for Commercial and Medicare plans.
• Gather information to support exception decisions and collaborate with pharmacists when needed.
• Prepare and adjust team schedules based on workload and objectives.
• Monitor KPI metrics and overall quality in coverage determinations and back-office tasks.
• Participate in testing and training for CMS-related changes to ensure compliance.
• Communicate departmental metrics and updates to clients and stakeholders.
• Mentor and develop team members, conduct performance reviews, and manage calibration processes.

Skills

Pharmacy Technician License

Team leadership

Bilingual Spanish/English

Communication skills

Relationship building

Education

Pharmacy Technician degree (Assoc or Bachelors)

Job description

Abarca Health LLC in San Juan, Puerto Rico, is seeking a Supervisor, Coverage Determination to oversee and coach the Coverage Determination team, ensuring cases are resolved accurately and on time across Commercial and Medicare plans. You will mentor staff, monitor KPI/quality, coordinate CMS compliance, assist with requests, and support training on CMS changes.

This role requires a Pharmacy Technician license, 6+ years in coverage determination, and Spanish-English fluency.