• What you’ll do
  • What you’re made of

In a few words…

As our ultra-knowledgeable Coverage Determination Specialist, you’ll be responsible for communicating with pharmacists, beneficiaries, and doctors in regards to pending coverage determinations for our clients’ beneficiaries. Being a Coverage Determination Specialist means you must comply with all federal rules and regulations, and with client contracts.

The fundamentals for the job…

  • Review and Respond (a type of R n’ R) to all Prior Authorization (PA) requests, and claims pending to be adjudicated for Medicare and/or Commercial-plan beneficiaries, always in an accurate and timely manner (only physicians and pharmacists may issue clinical denials).
  • Receive calls from pharmacies and members in relation to status of PA requests.
  • Initiate calls to physicians when additional information is required for processing and adjudicating a PA request.
  • Generate calls, faxes and/or letters to pharmacies and members in reference to prior authorization requests’ resolutions (as you can see, you’ll be on the phone a lot, so a courteous, warm, helpful and friendly attitude in every situation is essential).
  • Document PA request inquiries, issues, status and resolution in accordance with federal and department / company policies and guidelines.
  • Review faxes and create new cases for Medicare or Commercial plans.
  • Support Pharmacists in gathering additional information to support the decision of making an exception (formulary, non-formulary or other requests).
  • Available (and willing) to work rotating shifts, including nights, weekends, and holidays.

The bold requirements…

  • Pharmacy Technician Associate’s Degree; current/active Certified Pharmacy Technician License (preferred); Bachelor’s Degree (preferred). In addition, a minimum of 1 year working in a Pharmacy Call Center, OR 2 years working in a retail or hospital pharmacy setting, OR 3 years working in a non-pharmacy related customer service role. (In lieu of a degree, equivalent relevant work experience may be considered.)
  • If you have knowledge of PBM clinical operations and Medicare Part D, it counts as a plus.
  • Another plus is having previous experience in insurance, pharmacy, and / or healthcare setting (preferred).
  • Computer proficiency, knowledge of Microsoft Office products, and Internet experience (just the basics, digitally speaking).
  • Whatever else, one thing about you is for sure and that’s your superior interpersonal and customer service skills. You could teach a class on the subject.
  • You must be able to communicate effectively (read, write, speak, daydream, argue, text, etc.) in English and Spanish.

That something extra we´d love to see…

  • Analytical: You value the power of context & enjoy examining the past. You get the present by analyzing (sometimes over-analyzing) events leading up to it. This methodology is super helpful, but can provoke analysis-fatigue in those within earshot. Good thing you’re aware of this.
  • Detailed: Nothing gets by you and you rarely forget a thing. When learning some new procedure, you’re the type to take notes. When everyone else is still lost, you’re already at the next steps. Others count on this skill of yours.
  • Respectful: You are fair and aware of the need to treat people the same by setting up clear rules and adhering to them. Your interpersonal skills have opened many doors to you at every level.
  • Decisive: A bad decision is better than none. You know that not making a decision is to let life decide for you, so you take serious care in making choices even if you have doubts. You’re good at exit strategies.
  • People Person: You enjoy the challenge of meeting new people and winning them over. You feel rewarded just from breaking the ice and making a connection with another. You would probably make a great diplomat.

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

It is the policy of Abarca Health, LLC, its affiliates and subsidiaries (“Abarca”), to provide equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, genetics, or any other characteristic protected by federal, state or local law. In addition,. In addition to federal law requirements, Abarca complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

Abarca expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of Abarca’s employees to perform their job duties may result in discipline up to and including discharge.