Coverage Determination Specialist - Temp

Abarca Health • San Juan, PR

11d • Hybrid

About The Position

Abarca is seeking a Coverage Determination Specialist to join their team. This role involves creating and evaluating coverage determinations for clients, communicating with pharmacists, beneficiaries, and doctors, and applying clinical knowledge. The specialist must comply with all federal rules, regulations, and client contracts, and be willing to go the extra mile in each case. Abarca is described as a company revolutionizing healthcare through smarter technology, redefining pharmacy benefits.

Requirements

• Associate’s Degree in Pharmacy Technician (or equivalent, relevant work experience).
• 3+ years of experience in customer service.
• Experience with Microsoft Office tools (Outlook, Excel, Power Point, and Word).
• Excellent oral and written communication skills.
• Availability to work rotating shifts, including nights, weekends, and holidays.
• Availability to work in a specified time zone or working schedule, accommodating business needs.
• 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 a healthcare or pharmacy setting.

Responsibilities

• Review and respond to all Coverage Determination (CD) requests and claims pending adjudication for Medicare and/or Commercial-plan beneficiaries accurately and timely.
• Receive calls from pharmacies, physicians, and members regarding the status of CD requests.
• Initiate calls to physicians, pharmacies, 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 regarding the resolutions of coverage determination requests.
• Document 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 This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree