Supervisor, Coverage Determination
About The Position
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.
Requirements
- Associate or bachelor’s degree as a Pharmacy Technician is required.
- 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.
- Excellent oral and written communication skills.
- Bilingual fluency in Spanish and English is required.
Nice To Haves
- Current and Active Certified Pharmacy Technician License.
- Experience related with pharmacy benefit management (PBM) clinical operations and Medicare Part D.
Responsibilities
- 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.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
