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Abarca Health · 1 day ago

Coverage Determination Specialist

United States

Full-time

Remote

Mid Level

3+ years exp

Abarca is igniting a revolution in healthcare, redefining pharmacy benefits with smarter technology. As a Coverage Determination Specialist, you will create and evaluate coverage determinations, communicate with pharmacists, beneficiaries, and doctors, and ensure compliance with federal regulations.

Health CareInformation Technology

No H1B

Responsibilities

Review and Respond to all Coverage Determination (CD) requests, and claims pending to be adjudicated for Medicare and/or Commercial-plan beneficiaries, always in an accurate and timely manner

Receive calls from pharmacies, physicians and members in relation to status of CD requests

Initiate calls to physicians, pharmacy 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 in reference to coverage determination requests’ resolutions

Document Coverage Determination (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

Qualification

Associate’s Degree in Pharmacy Technician3+ years customer service experienceCertified Pharmacy Technician LicenseMicrosoft Office proficiencyFluency in EnglishSpanishExperience in healthcare settingCommunication skills

Required

Associate's Degree in Pharmacy Technician. (In lieu of a degree, equivalent, relevant work experience may be considered.)

3+ years of experience in customer service

Experience with Microsoft Office tools (Outlook, Excel, Power Point, and Word)

Available to work rotating shifts, including nights, weekends, and holidays

Excellent oral and written communication skills. Fluency in English and Spanish is required

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)