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 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.
The fundamentals for the job…
The bold requirements…
Abarca Health LLC is an equal employment opportunity employer and participates in E-Verify. “Abarca Health LLC does not sponsor employment visas at this time”
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.
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 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.
The fundamentals for the job…
- 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.
The bold requirements…
- Associate’s Degree in Pharmacy Technician. (In lieu of a degree, equivalent, relevant work experience may be considered.)
- 3+ years of experience in customer service.
- Experience with Microsoft Office tools (Outlook, Excel, Power Point, 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.
- We are proud to offer a flexible hybrid work model which will require certain on-site workdays (Puerto Rico Location Only)
- This position requires availability to work in a specified time zone or working schedule, accommodating the business needs of our clients and team members.
- This position may require availability for on-call hours, including evenings, weekends, and holidays, to promptly address emergent issues or provide necessary support as dictated by operational demands (if applicable).
- Certified Pharmacy Technician License is preferred.
- Experience in healthcare or pharmacy setting.
- Must be able to access and navigate each department at the organization’s facilities.
- Sedentary work that primarily involves sitting/standing.
Abarca Health LLC is an equal employment opportunity employer and participates in E-Verify. “Abarca Health LLC does not sponsor employment visas at this time”
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.
About the company
Company website•Hospitals and Health Care
Abarca is a pharmacy benefit manager (PBM) and healthcare technology company on a mission to make healthcare seamless and personalized for all.
For over 20 years, we've challenged the industry's status quo—replacing outdated systems with smarter technology, transparent pricing, and real partnerships that drive measurable results. Our platform, Darwin™, unites clinical, financial, and operational tools in a single intelligent solution to help payers, providers, and pharmacies simplify care, reduce costs, and improve outcomes.
From outcomes-based contracting to value-driven innovation and a culture built on bold ideas, we’re not just improving PBM—we’re redefining it.
We call it our Unstoppable Drive for a Better Way.
We're also the creators of Abarca Forward, a premier thought leadership event driving conversations that shape the future of healthcare.
Let’s build a better healthcare experience—together.
#PBMUnstoppable | #BetterWayForward 🚀