Job Description

We’re seeking individuals who are passionate about making a meaningful impact on how people experience pharmacy care. Below are two career paths within our pharmacy call center where your background and skills may align with current or future opportunities as they arise.

Coverage Determination

As a Coverage Determination Specialist you will be responsible to create and evaluate coverage determinations for our clients’. You will communicate with pharmacists, beneficiaries, and doctors regarding pending coverage determinations for our clients’ beneficiaries, applying clinical knowledge in each coverage determination case. You must comply with all federal rules and regulations, and client contracts and have disposition to give an extra mile in every coverage determination case. Main duties include:

• 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.

Rx Customer Service

As an Rx Customer Service Specialist, you will serve at the front line of all incoming and outgoing communication (calls, emails, and faxes) with pharmacies, beneficiaries, and prescribers. You will use Rx Platform and other resources as necessary to resolve caller’s needs. Main duties include:

• Manage all incoming calls, emails, faxes and web-generated requests from pharmacies, beneficiaries, and prescribers.
• Provide service-level standards set by CMS or by client; 80% of calls should fall within service level, less than 5% abandon rate and speed to answer should be less than 30 seconds.
• Rejection support, including overrides.
• Provide Coverage Determination status to clients including exceptions and appeals.
• Administrative PAs- Document PA request inquiries, issues, status, and resolution in accordance with federal and department and company policies and guidelines.
• Answer questions and recommend corrective services to address customer complaints, payment status, manual reversal requests, benefit and eligibility support, provider portal support and response to price appeals.
• Report identified issues to the appropriate department, for investigation and correction, following the established procedure.

The Bold Requirements...

• Associate degree in Pharmacy Technician.
• 1+ years of experience in customer service.
• Experience with Microsoft Office tools (Outlook, Excel, Power Point, and Word).
• Excellent oral and written communication skills. Fluency in English and Spanish is required.
• Available to work rotating shifts, including nights, weekends, and holidays.
• Available to work in a hybrid work model which will require certain on-site workdays.

Nice to have…

• Certified Pharmacy Technician License is preferred.
• Experience in healthcare or pharmacy setting is a plus.

Physical requirements…

• Must be able to access and navigate each department at the organization’s facilities.
• Sedentary work that primarily involves sitting/standing.

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

Abarca Health LLC is an equal employment opportunity employer and participates in E-Verify. “Applicant must be a United States’ citizen. Abarca Health LLC does not sponsor employment visas at this time”.

All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of gender, race/ethnicity, gender identity, sexual orientation, protected veteran status, disability, or other protected group status.

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