Coverage Determination Specialist - Temp

Abarca Health LLC.; San Juan (PR); Hybrid; USD 50,000 - 70,000; Full time

Job summary

Abarca Health LLC. is seeking a Coverage Determination Specialist to create and evaluate coverage determinations for Medicare and commercial plans. You will interact with pharmacists, providers, and members, applying clinical knowledge and ensuring CMS compliance.

A hybrid work model with Puerto Rico on-site days is required, with on-call hours possible. Qualified candidates have an Associate's Degree in Pharmacy Technician, 3+ years in customer service, and proficiency with Microsoft Office.

Qualifications

• Associate's Degree in Pharmacy Technician or equivalent work experience.
• 3+ years of experience in customer service.
• Experience with Microsoft Office tools (Outlook, Excel, Power Point, Word).
• Available to work rotating shifts, including nights, weekends, and holidays.
• Excellent oral and written communication skills.
• Hybrid work model with on-site days required for Puerto Rico location.
• Must be able to work in a specified time zone and accommodate business needs.
• May require on-call hours for emergent issues.

Responsibilities

• Create and evaluate coverage determinations for clients’ beneficiaries.
• Communicate with pharmacists, beneficiaries, and doctors regarding CD status.
• Apply clinical knowledge to each coverage determination case.
• Ensure CMS or other regulations are followed in determinations.
• Review requests and generate follow-up calls, faxes, or letters as needed.
• Document inquiries, status, and resolutions in accordance with policies.

Skills

Customer service

Communication

Pharmacy knowledge

Education

Associate's Degree in Pharmacy Technician

Tools

Microsoft Office

Job description

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…

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.
• We are proud to offer a flexible hybrid work model which will require certain on-site work-days (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 haves...

• 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.