Job Opportunities API

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 the Supervisor, Coverage Determination you’ll support oversight management by coaching, training, and supporting the Coverage Determination team. You’ll assist the specialists with all incoming cases to ensure all Commercial and Medicare coverage determination cases are resolved correctly and on time. You’ll learn and collaborate with additional peers in leadership to ensure all your team members are up to date with the latest changes in regulation (whether state or federally mandated). Additionally, we’ll need your guidance on KPI 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. Assist CD Specialists  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). Support Pharmacists in gathering additional  information to support the decision making of an exception  request  ( whether  formulary, non-formular , etc. ). Prepare team schedules while taking into consideration work volume, team   objectives , personnel availability, and seasonal events . 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. Responsible for mentoring, development of team, performance review, growth conversation, and calibration processes.   Support the Knowledge Accelerator team in creating content, as needed, for training on subject matter expertise  and process.     What we expect of you:     The bold requirements…    Associate  or bachelor’s  degree  as a Pharmacy Technician is  required .    6+ years of  experience managing coverage determination processes , including 1+ years of experience leading a team.   Experience related to industries  such as  insurance, pharmacy, or healthcare .  Ability to develop relationships and maintain  customer support through superior interpersonal and customer service skills .  Excellent oral and written communication skills.   Bilingual fluency in Spanish and English is  required