Supervisor, Coverage Determination

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

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 the Supervisor, Coverage Determination you’ll support oversight management by coaching, training, and supporting the Coverage Determination team. You’ll assist the specialists with all incoming cases to ensure all Commercial and Medicare coverage determination cases are resolved correctly and on time. You’ll learn and collaborate with additional peers in leadership to ensure all your team members are up to date with the latest changes in regulation (whether state or federally mandated). Additionally, we’ll need your guidance on KPI and quality monitoring while complying with all federal rules and regulations as well as client contracts.

The fundamentals for the job…

• Monitor calls and cases to ensure that all are resolved in a timely and appropriate manner while meeting with respective levels of quality.
• Accomplish key performance (KPI) metrics for cases and areas as assigned.
• Monitor coverage determination performance metrics to ensure proper adjustments are made in a timely manner and the coverages are managed within the standards set by Centers for Medicare & Medicaid Services (CMS) as well as clients.
• Assist CD Specialists in responding to coverage determination requests, and claims pending to be adjudicated for Commercial and Medicare-plan beneficiaries in an accurate and timely manner, when needed (only physicians and pharmacists may issue clinical denials).
• Support Pharmacists in gathering additional information to support the decision making of an exception request (whether formulary, non-formular, etc.).
• Prepare team schedules while taking into consideration work volume, team objectives, personnel availability, and seasonal events.
• Monitor coverage determination cases and back-office duties for quality, compliance, and employee development purposes.
• Participate in testing and training of all technical changes/enhancements to the Coverage Determination Module to ensure compliance with CMS or other regulating entities.
• Participate in interactions with clients to provide overview on departmental metrics and other assigned areas.
• Ensure compliance with Centers for Medicare & Medicaid Services (CMS) policies as well as other regulating entities related to coverage determinations.
• Responsible for mentoring, development of team, performance review, growth conversation, and calibration processes.
• Support the Knowledge Accelerator team in creating content, as needed, for training on subject matter expertise and process.

What we expect of you

The bold requirements…

• Associate or bachelor’s degree as a Pharmacy Technician is required.
• Current and Active Certified Pharmacy Technician License.
• 6+ years of experience managing coverage determination processes, including 1+ years of experience leading a team.
• Experience related to industries such as insurance, pharmacy, or healthcare.
• Ability to develop relationships and maintain customer support through superior interpersonal and customer service skills.
• Bilingual fluency in Spanish and English is required.
• 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...

• Experience related with pharmacy benefit management (PBM) clinical operations and Medicare Part D.

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.