Coverage Determination Specialist

hace 4 semanas


San Juan, San Juan, Puerto Rico abarca health A tiempo completo

About the Role

Abarca 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 Responsibilities

  • Review and respond to all coverage determination requests and claims pending to be adjudicated for Medicare and/or Commercial-plan beneficiaries.
  • Receive calls from pharmacies, physicians, and members regarding the status of coverage determination requests.
  • Initiate calls to physicians, pharmacies, and members when additional information is required for processing and adjudicating a coverage determination request.
  • Generate calls, faxes, and/or letters to pharmacies, physicians, and members regarding coverage determination requests' resolutions.
  • Document coverage determination requests, 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.

Requirements

  • Associate degree in Pharmacy Technician or equivalent relevant work experience.
  • 3+ years of experience in customer service.
  • Experience with Microsoft Office tools (Outlook, Excel, PowerPoint, 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.


  • San Juan, San Juan, Puerto Rico abarca health A tiempo completo

    About Abarca HealthAbarca Health is a revolutionary company that's redefining pharmacy benefits through smarter technology. Our mission is to deliver exceptional healthcare services while ensuring the satisfaction of our clients and beneficiaries.Job SummaryWe're seeking a highly skilled Coverage Determination Team Manager to oversee the Coverage...


  • San Juan, San Juan, Puerto Rico abarca health A tiempo completo

    About 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...


  • San Juan, San Juan, Puerto Rico abarca health A tiempo completo

    About 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...

  • Senior Account Manager

    hace 4 semanas


    San Juan, San Juan, Puerto Rico Risk Strategies A tiempo completo

    Job SummaryRisk Strategies is seeking a highly skilled Senior Account Manager to join our team. As a key member of our Private Client Services group, you will be responsible for developing and maintaining strong relationships with our high net worth clients.Key ResponsibilitiesBuild and maintain constructive relationships with clients by meeting and...


  • San Juan, San Juan, Puerto Rico AIG A tiempo completo

    AIG is a global leader in commercial and personal insurance solutions, seeking an experienced Risk Management Specialist to join our team.This role offers a unique opportunity to contribute to the development of innovative insurance solutions for clients across various industries. As a Risk Management Specialist, you will be responsible for evaluating risks,...


  • San Juan, San Juan, Puerto Rico First Chicago Insurance Company A tiempo completo

    We are seeking an experienced Auto Bodily Injury Claims Specialist to join our team at First Chicago Insurance Company. Our new office in Oak Brook is now open, and we are excited to expand our operations in the area.The Bodily Injury Claims Specialist will be responsible for investigating and settling automobile bodily injury claims. They will work closely...

  • Dental Care Specialist

    hace 2 semanas


    San Juan, San Juan, Puerto Rico Great Expressions Dental Centers A tiempo completo

    Job Title: Dental Care SpecialistAt Great Expressions Dental Centers, we're seeking a skilled Dental Care Specialist to join our team. As a key member of our dental practice, you'll be responsible for delivering high-quality oral care to our patients.Key Responsibilities:Conduct thorough dental exams and diagnose oral health issuesDevelop and implement...


  • San Juan, San Juan, Puerto Rico Mitchell Martin A tiempo completo

    At Mitchell Martin, we're seeking an experienced Diagnostic Imaging Specialist to join our team in a CT Technologist Position. As a Radiology Technician Role, you'll be responsible for performing routine radiological procedures and operating CT equipment to produce high-quality images of patients' bones, organs, and tissue. **Responsibilities:** • Operate...


  • San Juan, San Juan, Puerto Rico Colin Fane - State Farm Agent A tiempo completo

    We are seeking a highly skilled Customer Support Specialist to join our team at Colin Fane - State Farm Agent. As a Customer Support Specialist, you will be the first point of contact for our customers, providing exceptional service and support to ensure their needs are met.Key Responsibilities:Customer Support: Delivering exceptional customer service by...

  • Credit Specialist Manager

    hace 4 semanas


    San Juan, San Juan, Puerto Rico KPMG-UnitedStates A tiempo completo

    Job Title: Manager, Credit SpecialistKPMG-UnitedStates is seeking a skilled Credit Specialist Manager to join our Audit practice. As a key member of our team, you will be responsible for managing and supervising the execution of credit specialist components of external audit engagements for various clients, including Securities and Exchange Commission (SEC)...


  • San Juan, San Juan, Puerto Rico Firma de Reclutamiento en PR A tiempo completo

    We are seeking a highly skilled Risk Management Specialist to help our clients achieve their goals by implementing effective solutions to manage their risks. The ideal candidate will be responsible for advising internal and external producers on personal lines insurance, effectively managing risks, and completing the underwriting process in accordance with...


  • San Juan, San Juan, Puerto Rico AIG A tiempo completo

    About the Role:As a Financial Claims Specialist at AIG, you will be responsible for assessing and managing complex liability claims within authority limits. You will perform coverage and quantum analysis throughout the claims' lifecycles, ensuring timely and accurate resolutions for our customers.What You'll Do:Proactively assess and manage complex liability...


  • San Juan, San Juan, Puerto Rico Wal-Mart Stores, Inc. A tiempo completo

    Job SummaryWe are seeking a highly organized and detail-oriented Administrative Support Specialist to join our team. As a key member of our operations team, you will provide administrative support through generating and maintaining forms, reports, and logs via computerized management software. Your ability to be accurate and focus on attention to details...

  • Insurance Risk Analyst

    hace 3 semanas


    San Juan, San Juan, Puerto Rico Hub International A tiempo completo

    Job SummaryAs a Coverage Specialist at Hub International, you will be responsible for analyzing insurance applications and determining coverage amounts and premiums. This is a full-time remote role that requires strong analytical skills and attention to detail.Key ResponsibilitiesAnalyze insurance applications to determine coverage amounts and...


  • San Juan, San Juan, Puerto Rico Oneoncology A tiempo completo

    About The Cancer & Hematology CentersThe Cancer & Hematology Centers is a leading independent community oncology practice dedicated to providing specialized care and access to the latest treatments and research trials in a compassionate environment. Our practice is committed to helping, healing, and hope for cancer patients and their families.Opportunity...

  • Order Filler

    hace 7 días


    San Juan, San Juan, Puerto Rico Advance Auto Parts A tiempo completo

    Job OverviewAt Advance Auto Parts, we're dedicated to providing excellent customer service and ensuring timely order fulfillment. As an Order Filler - Inventory Specialist, you will play a critical role in preparing orders for shipment while maintaining a clean and organized warehouse environment.About the RoleThis is a fantastic opportunity for individuals...

  • Bar Support Specialist

    hace 2 semanas


    San Juan, San Juan, Puerto Rico Dave & Buster's, Inc. A tiempo completo

    About the Role:We are seeking a skilled Bar Support Specialist to join our team at Dave & Buster's, Inc. This individual will be responsible for assisting bartenders in maintaining a clean and stocked bar area, ensuring prompt and friendly service to our guests.Key Responsibilities:Deliver an exceptional guest experience by providing excellent service and...


  • San Juan, San Juan, Puerto Rico Sargent & Lundy A tiempo completo

    Job SummarySargent & Lundy is seeking a highly skilled Senior Instrumentation Specialist to join our team. As a key member of our project team, you will be responsible for designing, modifying, and analyzing power plant controls systems.Key ResponsibilitiesDesign and develop digital systems, including PLC, DCS, HSI, and networked computer systems.Develop...


  • San Juan, San Juan, Puerto Rico Sargent & Lundy A tiempo completo

    About the JobSargent & Lundy is seeking an experienced Electrical Engineering Specialist to join our Energy & Industrial Group. As a member of our project team, you will be responsible for designing and modifying electrical systems for power plants.Key ResponsibilitiesDevelop single-line diagrams, relay and metering diagrams, and AC and DC schematic...


  • San Juan, San Juan, Puerto Rico California Department Of Education A tiempo completo

    **Job Summary**Under the supervision of the classroom teacher, the Education Support Specialist will assist in the supervision and intensified learning instruction of students in assigned areas of study. This role will also perform classroom clerical tasks in support of the instructional process. The work schedule is 7:45 am - 1:45 pm, Monday - Friday, with...