Supervisor, Coverage Determination

Abarca Health•San Juan, PR

6d•Hybrid

About The Position

Abarca is seeking a Supervisor, Coverage Determination to provide oversight management by coaching, training, and supporting the Coverage Determination team. This role involves assisting specialists with incoming cases to ensure accurate and timely resolution of Commercial and Medicare coverage determination cases. The supervisor will collaborate with other leaders to keep the team updated on regulatory changes and will guide KPI and quality monitoring while ensuring compliance with federal rules, regulations, and client contracts.

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.
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.
Availability to work in a specified time zone or working schedule, accommodating business needs.
Availability for on-call hours, including evenings, weekends, and holidays, if applicable.

Nice To Haves

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

Responsibilities

Monitor calls and cases to ensure timely and appropriate resolution with respective quality levels.
Accomplish key performance (KPI) metrics for assigned cases and areas.
Monitor coverage determination performance metrics to ensure proper adjustments are made in a timely manner and coverages are managed within the standards set by Centers for Medicare & Medicaid Services (CMS) and clients.
Assist CD Specialists in responding to coverage determination requests and claims pending adjudication for Commercial and Medicare-plan beneficiaries accurately and timely, when needed.
Support Pharmacists in gathering additional information to support decision-making for exception requests.
Prepare team schedules considering work volume, team objectives, personnel availability, and seasonal events.
Monitor coverage determination cases and back-office duties for quality, compliance, and employee development.
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 client interactions to provide an overview of departmental metrics and other assigned areas.
Ensure compliance with Centers for Medicare & Medicaid Services (CMS) policies and other regulating entities related to coverage determinations.
Mentor, develop the team, conduct performance reviews, facilitate growth conversations, and manage calibration processes.
Support the Knowledge Accelerator team in creating content for training on subject matter expertise and processes, as needed.