Medicare Coverage Determination Expert

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

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.