Description

You will create and evaluate coverage determinations for clients' beneficiaries, communicating with pharmacists, beneficiaries, and doctors to ensure timely and accurate processing. This role is key to maintaining compliance with federal regulations and delivering high-quality service in pharmacy benefits.

Requirements

• Associate degree in Pharmacy Technician.
• 3+ years of customer service experience.
• Experience with Microsoft Office (Outlook, Excel, PowerPoint, Word).
• Available to work rotating shifts including nights, weekends, and holidays.
• Excellent oral and written communication skills.
• Fluency in English and Spanish.
• Must be a United States citizen.

Responsibilities

• Review and respond to Coverage Determination (CD) requests and claims pending adjudication for Medicare and/or Commercial-plan beneficiaries.
• Receive calls from pharmacies, physicians, and members regarding CD request status.
• Initiate calls to physicians, pharmacies, and members for additional information.
• Generate calls, faxes, and/or letters regarding CD request resolutions.
• Document CD request inquiries, issues, status, and resolution according to policies.
• Review faxes and emails to create new cases for Medicare/Medicaid or Commercial plans.
• Support Pharmacists in gathering information for exception decisions.
• Ensure CMS compliance or other regulatory requirements related to coverage determinations.
• Complete other CD-related tasks as assigned.