Coverage Determination Specialist- Temp
Abarca Health Ver todas las vacantes
- San Juan, PR
- Permanente
- Tiempo completo
- 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.
- 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.
- Must be able to access and navigate each department at the organization's facilities.
- Sedentary work that primarily involves sitting/standing.