Pharmacy Coverage Determination & Appeals Specialist

Triple-S; Guaynabo (PR); On-site; USD 32,000 - 42,000; Full time

Job summary

Triple-S in Puerto Rico seeks a Pharmacy Technician to handle Coverage Determination in the Pharmacy Department, ensuring compliance with CMS, ASES, URAC, and state requirements. You will gather clinical information, liaise with physicians, pharmacies, and enrollees, and document decisions for timely responses.

The role emphasizes accuracy in plan decisions, adherence to regulatory criteria, and effective communication with stakeholders to support patient access to medications and services.

Qualifications

• Pharmacy Technician course and one year of experience.
• Active, unrestricted Pharmacy Technician license in Puerto Rico.
• Ability to communicate with physicians, pharmacies, and enrollees.
• Compliance with CMS, ASES, URAC, and state laws.

Responsibilities

• Evaluate Coverage Determination requests and classify them per CMS and internal policies.
• Gather clinical information to support evaluations.
• Contact physicians, pharmacies, or enrollees to obtain needed information.
• Document all efforts in the system and communicate final decisions.
• Prepare letters to inform parties of decisions.
• Provide orientation on Coverage Determination and Appeals processes.
• Notify status via outbound calls to stakeholders.
• Ensure clinical accuracy of plan decisions with regulatory criteria.
• Identify trends in complaints and assist in action plans.

Skills

Pharmacy procedures

Clinical data collection

Customer service

Education

Technical Course in Pharmacy

Lic. Pharmacy Technician

Job description

Triple-S in Puerto Rico seeks a Pharmacy Technician to handle Coverage Determination in the Pharmacy Department, ensuring compliance with CMS, ASES, URAC, and state requirements. You will gather clinical information, liaise with physicians, pharmacies, and enrollees, and document decisions for timely responses.

The role emphasizes accuracy in plan decisions, adherence to regulatory criteria, and effective communication with stakeholders to support patient access to medications and services.