- 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.
- Associate 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.
- Certified Pharmacy Technician License is preferred.
- Experience in healthcare or pharmacy setting is a plus.
- Analytical
- Detailed
- Action for Bias
- Must be able to access and navigate each department at the organization's facilities.
- Sedentary work that primarily involves sitting/standing.
-
Team Leader, Coverage Determination
hace 1 día
abarca health San Juan, Puerto RicoWhat you'll do · 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. · Abarca's Service Operations team takes the charge by handling two areas of detai ...
-
eCOB Specialist II
hace 6 días
Elevance Health San Juan, Puerto Rico De jornada completaJob Description · : eCOB Specialist II · Location: Hybrid, within 50 miles of Elevance Health PulsePoint location. · Hours: Monday-Friday, an 8-hour shift between the hours of 6am-6pm. · An eCOB Specialist II is responsible for researching and investigating other coverage f ...
-
Senior Pursuit Leader – High Growth Services
hace 5 días
KPMG-UnitedStates San Juan, Puerto RicoBusiness Title:Senior Pursuit Leader – High Growth Services (HGS) & TechRequisition Number: Function:Business Support Services · Area of Interest:State:VT · City:Colchester · Description: · Known for being a great place to work and build a career, KPMG provides audit, tax and adv ...
-
Clinical Reviewer
hace 2 días
UnitedHealth Group San Juan, Puerto Rico De jornada completaOptum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel ...
-
Auto Adjuster
hace 3 días
Firma de Reclutamiento en PR San Juan, Puerto RicoResponsibilities: · Evaluate, analyze and adjust claims according to policies. · Examine property claim forms and other records to determine insurance coverage. · Analyze and verify insurance claims for accuracy, completeness, and eligibility. · Investigate and assess damage to ...
-
Sales Clerk Int 5690
hace 6 días
Coast Guard Exchange Caguas, Puerto Rico Intermittent 0-19 hrsDUTIES · : Welcome customers, maintain product knowledge and help with the selection of merchandise. React to all concerns of customers quickly with a sense of importance. Sell merchandise, and provide outstanding customer service, which may require demonstration and/or explana ...
-
Sales Development Program
hace 2 días
UnitedHealth Group San Juan, Puerto Rico De jornada completaOptum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel ...
-
Underwriting Support Specialist
hace 1 semana
Taleo Be San Juan, Puerto RicoUnderwriting Support Specialist American International Group, Inc. (AIG) is a leading global insurance organization. AIG member companies provide a wide range of property casualty insurance in approximately 70 countries and jurisdictions. These diverse offerings include products ...
-
Face to Face Fundraising- Save the Children
hace 1 día
Dialoguedirect San Juan, Puerto Rico De jornada completa$85,000/year OTE (On Target Earning) · Join Our Team as a Campaign Manager. Are you passionate about driving impactful change and empowering communities? We are seeking a skilled and dedicated Campaign Manager to lead our fundraising efforts and make a difference in the lives of ...
-
Sales Representative 4
hace 1 día
AbbVie San Juan, Puerto Rico De jornada completaJob Description · The Sales Representative 4 for the Neuroscience area will be responsible for executing brand strategy and tactics in the field, sales performance, effectively manage assigned territory and targeted accounts, building strong customer relationships, and customer n ...
-
Health & Life distribution manager
hace 22 horas
Firma de Reclutamiento en PR San Juan, Puerto RicoKey ResponsibilitiesProduct Development: Collaborate with insurance carriers to develop and refine insurance products that precisely meet customer needs. · Digital Strategy: Significantly enhance the digital footprint by integrating insurance offerings into the Company web platfo ...
-
Manager, Strategic Corporate Tax
hace 5 días
KPMG-UnitedStates San Juan, Puerto RicoBusiness Title:Manager, Strategic Corporate TaxRequisition Number: Function:Tax Services · Area of Interest:State:PR · City:San Juan · Description: · At KPMG, you can become an integral part of a dynamic team at one of the world's top tax firms. Enjoy a collaborative, future-forw ...
-
Marine Claims Adjuster
hace 1 día
AIG San Juan, Puerto Rico De jornada completaWho we are: · AIG is a leading provider of insurance products and services for commercial and personal insurance customers. It includes one of the world's most far-reaching property casualty networks. AIG offers a broad range of products to customers through a diversified, multic ...
-
Marine Claims Adjuster
hace 1 día
AIG San Juan, Puerto Rico De jornada completaWho we are: · AIG is a leading provider of insurance products and services for commercial and personal insurance customers. It includes one of the world's most far-reaching property casualty networks. AIG offers a broad range of products to customers through a diversified, multic ...
-
Senior Associate, Business Tax Services
hace 6 días
KPMG-UnitedStates San Juan, Puerto RicoBusiness Title:Senior Associate, Business Tax ServicesRequisition Number: Function:Tax Services · Area of Interest:State:PR · City:San Juan · Description: · At KPMG, you can become an integral part of a dynamic team at one of the world's top tax firms. Enjoy a collaborative, futu ...
-
Accountant
hace 14 horas
Empower Human Resources Carolina, Puerto Rico- Prepare, examine, or analyze accounting records, financial statements, or other financial reports to assess accuracy, completeness, and conformance to reporting and procedural standards.- Prepare adjusting journal entries.- Review accounts for discrepancies and reconcile differ ...
Specialist, Coverage Determination - San Juan, Puerto Rico - abarca health
Descripción
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...
Providing high quality services to client and beneficiaries is at the core of what we do every day The PBM Operations & Services team is the very heart of Abarca and meets that standard by running services from medication therapy management programs, price eligibility, configurations and beneficiary services to government services and beyond. Within Coverage Determination, our teams handle case determination, triaging calls from physicians and pharmacies among other support items.
As a Coverage Determination Specialist you will be responsible to create and evaluate coverage determinations for our clients'. You will communicate with pharmacists, beneficiaries, and doctors regarding pending coverage determinations for our clients' beneficiaries, applying clinical knowledge in each coverage determination case. You must comply with all federal rules and regulations, and client contracts and have disposition to give an extra mile in every coverage determination case.
The fundamentals for the job...
What you're made of
The bold requirements...
Nice to have...
That something extra we ́d love to see...
Physical requirements...
