Coverage Determination Specialist (6-month temp contract)

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 ...

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...

• 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.

What we expect of you

The bold requirements...

Nice to have...

Physical requirements...

At Abarca we value and celebrate diversity. Diversity, equity, inclusion, and belonging are guiding principles of Abarca and ensure Abarca's workforce reflects the communities it serves. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

Abarca Health LLC is an equal employment opportunity employer and participates in E-Verify. "Abarca Health LLC does not sponsor employment visas at this time"

The above description is not intended to limit the scope of the job or to exclude other duties not mentioned. It is not a final set of specifications for the position. It's simply meant to give readers an idea of what the role entails.

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