Abarca Health · 1 day ago
Coverage Determination Specialist (Temp)
United States
Full-time
Remote
Mid Level
3+ years expAbarca is igniting a revolution in healthcare, focusing on redefining pharmacy benefits through smarter technology. As a Coverage Determination Specialist, you will be responsible for creating and evaluating coverage determinations, communicating with various stakeholders, and ensuring compliance with federal regulations.
Health CareInformation Technology
No H1B
Responsibilities
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
Qualification
Required
Associate's 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
This position requires availability to work in a specified time zone or working schedule, accommodating the business needs of our clients and team members
This position may require availability for on-call hours, including evenings, weekends, and holidays, to promptly address emergent issues or provide necessary support as dictated by operational demands (if applicable)
Preferred
Certified Pharmacy Technician License is preferred
Experience in healthcare or pharmacy setting
Company
Abarca Health
Abarca Health is an information technology company that offers healthcare IT services
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
Adriana Ramirez
President & COO
Recent News
News is my Business
2025-10-31
News is my Business
2025-03-27
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