Team Leader, Coverage Determination
hace 5 meses
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…
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.What you’re made of
The bold requirements…
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.That something extra we´d love to see…
Analytical Accountable and Responsible Strategic Planner Self Sufficient CommunicatorPhysical requirements…
Must be able to access and navigate each department at the organization’s facilities. Sedentary work that primarily involves sitting/standing.-
Team Leader, Coverage Determination Specialist
hace 7 días
San Juan, San Juan, Puerto Rico abarca health A tiempo completoAbout the RoleAbarca Health is seeking a highly skilled Team Leader to oversee the Coverage Determination team. As a key member of our Service Operations team, you will be responsible for ensuring the timely and accurate resolution of Commercial and Medicare coverage determination cases.Key ResponsibilitiesMonitor calls and cases to ensure timely and...
-
Coverage Determination Specialist
hace 2 semanas
San Juan, San Juan, Puerto Rico abarca health A tiempo completoAbout the RoleAbarca Health is seeking a highly skilled and detail-oriented Coverage Determination Specialist to join our team. In this role, you will be responsible for creating and evaluating coverage determinations for our clients, communicating with pharmacists, beneficiaries, and doctors, and applying clinical knowledge to each case.Key...
-
Specialist, Coverage Determination
hace 5 meses
San Juan, Puerto Rico abarca health A tiempo completoWhat 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… Providing high quality services to client and beneficiaries is at the core of what we do every day! The PBM Operations & Services team is...
-
Coverage Determination Specialist
hace 2 semanas
San Juan, San Juan, Puerto Rico abarca health A tiempo completoAbout the RoleAbarca Health is seeking a skilled Coverage Determination Specialist to join our team. As a key member of our PBM Operations & Services team, you will play a critical role in providing high-quality services to our clients and their beneficiaries.Key ResponsibilitiesReview and respond to coverage determination requests and claims pending...
-
Healthcare Coverage Specialist
hace 1 día
San Juan, San Juan, Puerto Rico abarca health A tiempo completoAbout the roleAbarca Health is seeking a skilled professional to join our PBM Operations & Services team as a Coverage Determination Specialist.The ideal candidate will possess strong analytical skills and the ability to communicate effectively with pharmacists, beneficiaries, and doctors.Responsibilities will include reviewing and responding to coverage...
-
Team Leader
hace 5 meses
San Juan, Puerto Rico abarca health A tiempo completoWhat 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... Abarca’s Service Operations team takes the charge by handling two areas of detail-oriented and quality care: Clinical Outreach and...
-
Tax Office Associate Team Leader
hace 2 semanas
San Juan, San Juan, Puerto Rico H&R Block, Inc. A tiempo completoAbout the RoleWe are seeking a highly skilled and experienced Tax Office Associate Team Leader to join our team at H&R Block, Inc. As a key member of our team, you will be responsible for supporting the Multi-Unit Team Leader and serving as the onsite point of contact for tax office associates and clients.Key ResponsibilitiesExecute and hold tax office...
-
Key Team Leader
hace 2 semanas
San Juan, San Juan, Puerto Rico Dunhams Sports A tiempo completoJob Title: Key Team LeaderJob Summary: We're seeking a highly skilled and enthusiastic individual to join our team as a Key Team Leader. As a key member of our team, you will be responsible for providing excellent customer service and supporting the sales team in achieving our goals.Key Responsibilities:Provide exceptional customer service and support to our...
-
Optical Team Leader Position
hace 1 día
San Juan, San Juan, Puerto Rico EssilorLuxottica Group A tiempo completoJob Description:Requisition ID: 858192Store #: 000474 LensCraftersPosition: Full-TimeTotal Rewards: Benefits/Incentive InformationLensCrafters is a leading optical retailer in North America with over 1,000 stores and a legacy of 35 years. We're seeking a skilled Optical Team Leader to join our team.As an Optical Team Leader, you will be responsible for...
-
Merchandiser Retail Coverage Specialist
hace 2 semanas
San Juan, San Juan, Puerto Rico Acosta Group A tiempo completoJob Title: Merchandiser Retail Coverage II - Walmart - FLOATERJob Summary:We are seeking a highly motivated and detail-oriented Merchandiser Retail Coverage II to join our team at Acosta Group. As a Merchandiser Retail Coverage II, you will be responsible for ensuring Acosta's client brands stand out at Walmart stores by driving product availability. Your...
-
Food and Beverage Team Leader Position
hace 2 días
San Juan, San Juan, Puerto Rico Target A tiempo completoFood and Beverage Team Leader Job SummaryWe are seeking a skilled Food and Beverage Team Leader to join our team at Target. As a Food and Beverage Team Leader, you will be responsible for leading a team of hourly team members to deliver exceptional guest service and sales goals in the Food and Beverage department.Key Responsibilities:Lead and motivate team...
-
Team Leader
hace 2 días
San Juan, San Juan, Puerto Rico ABM A tiempo completoJob Summary:The Cleaning Operations Manager is responsible for leading a team of cleaners and ensuring the highest level of service is delivered to our clients. This role requires strong leadership and communication skills, as well as the ability to motivate and guide team members to achieve their best.Key Responsibilities:Provide leadership and direction to...
-
Multi-Unit Team Leader Position
hace 2 semanas
San Juan, San Juan, Puerto Rico H&R Block A tiempo completoAbout the RoleAt H&R Block, we're seeking a highly skilled and experienced Multi-Unit Team Leader to join our team. As a key member of our leadership team, you will be responsible for managing multiple tax offices, providing leadership and development to our associates, and driving business growth.Key ResponsibilitiesManage office staffing, operations, and...
-
Team Lead, Medicare Part D Operations
hace 4 meses
San Juan, Puerto Rico abarca health A tiempo completoWhat 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... Providing high quality services to client and beneficiaries is at the core of what we do every day! The Pharmacy Benefit Management...
-
Selling Team Leader
hace 1 semana
San Juan, San Juan, Puerto Rico American Eagle Outfitters A tiempo completoJob SummaryWe are seeking a highly motivated and experienced Selling Team Leader to join our team. As a key member of our store leadership, you will be responsible for driving sales, leading a high-performing team, and delivering exceptional customer service.Key ResponsibilitiesDevelop and implement sales strategies to drive business growth and meet sales...
-
Store Team Leader
hace 2 semanas
San Juan, San Juan, Puerto Rico Lovisa A tiempo completoJob OverviewAbout LovisaLovisa is a leading fashion-forward jewelry brand that caters to every woman, with a strong presence in 20 countries worldwide.We are committed to delivering exceptional customer service and providing a unique shopping experience that sets us apart from the competition.Key Holder RoleThe Key Holder is a critical member of our store...
-
Determination Letter Coordinator
hace 1 semana
San Juan, Puerto Rico UnitedHealth Group A tiempo completoOptum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion,...
-
Team Leader-Housekeeping
hace 5 meses
San Juan, Puerto Rico Marriott International A tiempo completoPOSITION SUMMARY Enter status of rooms cleaned. Complete checklists to report cleanliness and condition of each assigned area. Complete required Housekeeping paperwork. Identify room assignments and type of cleaning required for each room. Inspect guest rooms after being cleaned by Housekeeper. Respond promptly to requests from guests and other...
-
Executive Leader
hace 1 semana
San Juan, San Juan, Puerto Rico Jobleads-Us A tiempo completoWild Fire Harley-Davidson Overview:Are you an experienced leader looking to take your career to the next level? Windy City-Fox Motorsports is seeking a General Manager for our Harley-Davidson/Metric Bike dealership in Villa Park, IL. As a company founded by riders for riders, we are dedicated to setting the new retail standard in the motorcycle industry.Key...
-
Shift Leader
hace 2 días
San Juan, San Juan, Puerto Rico Luna Grill A tiempo completoJob SummaryWe are seeking a skilled Shift Leader to join our team at Luna Grill. As a Shift Leader, you will be responsible for ensuring seamless operations during your shifts, providing exceptional guest service, and maintaining high standards of quality and safety.Key Responsibilities:Assist in inspiring and developing your team to deliver exceptional...