- 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.
- Provide leadership guidance, training and mentoring for the Senior & Coverage Determination Specialist team members.
- Assist 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).
- Receive calls from pharmacies, physician and members related to the status of coverage determination (CD) requests.
- Initiate calls to physicians when additional information is required for processing and adjudicating coverage determination (CD) requests.
- Generate calls to pharmacies and members in reference to coverage determination (CD) request resolution.
- Support Pharmacists in gathering additional information to support the decision making of an exception request (whether formulary, non-formulary, etc.).
- Document coverage determination (CD) request inquiries, issues, statuses, and resolutions to ensure all is in accordance with federal and department guidelines, company policies and attestations.
- Develop quarterly schedules for specialists while considering and planning towards operational needs of payroll processes.
- 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.
- Perform other duties and special projects as assigned.
- Completed Associate's Degree as a Pharmacy Technician is required. Having a Bachelor's degree is preferred.
- Current and Active Certified Pharmacy Technician License is preferred.
- Minimum of 5 years of experience managing coverage determination processes.
- Knowledge of pharmacy benefit management (PBM) clinical operations and Medicare Part D is preferred.
- Prior experience in industries such as insurance, pharmacy, and / or healthcare is preferred.
- Able to leverage analytical and critical thinking to deploy great organizational skills and keep detail-oriented outlook on processes.
- Ability to develop relationships and maintain customer support through superior interpersonal and customer service skills
- Must have strong communications skills both oral and written.
- Strong communication skills both oral and written. Bilingual fluency in English and Spanish is required for this role.
- Analytical
- Accountable and Responsible
- Strategic
- Planner
- Self Sufficient
- Communicator
- Must be able to access and navigate each department at the organization's facilities.
- Sedentary work that primarily involves sitting/standing.
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Team Leader, Coverage Determination - San Juan, Puerto Rico - abarca health
Descripción
What 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 detail-oriented and quality care: Clinical Outreach and Services. From maintain the health of our beneficiaries through case management and Medication Therapy Management Programs (MTM) to addressing eligibility requests or price appeal considerations, this team goes above and beyond to ensure the client and beneficiary are satisfied They assist in major areas such as Coverage Determination that cover cases prior to adjudication, and triaging calls from physicians and pharmacies; Rx Customer Service for conducting satisfaction surveys, addressing complaints, managing manual reversal requests; Clinical Outreach for case management and beneficiary lifestyle care as well as MTM program management; and lastly, Clinical Services for our myriad of clinical programs (MTMP, HCIP, Hepatitis, etc.) and collaboration with our pharmacists as well as pharmacy consultants. We are seeking a Team Leader to support the Coverage Determination team.
In this critical role as the Team Leader for Coverage Determination you will support oversight management of the Coverage Determination team in this role you will assist the specialists with all incoming cases especially escalations to ensure all Commercial and Medicare coverage determination cases are resolved correctly and on-time. You will ensure all your team members are up to date with the latest changes in regulation (whether state or federally mandated). Additionally, provide guidance on KPIs and quality monitoring while complying with all federal rules and regulations as well as client contracts.
The fundamentals for the job...
What you're made of
The bold requirements...
That something extra we ́d love to see...
Physical requirements...
Profesionales que compiten contigo
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Mabel Lynette Morales
Physician assistant
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Kamila Sofia Aviles Torres
Estudiante Graduada de Ciencias Naturales