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Coverage Determination Manager Part B

Location : Guaynabo
Job Type : Direct
Hours : Full Time
Travel : No
Relocation : No

Job Description :

Under the leadership of the Operations Director the main objective of this role is to provide ongoing oversight of the Coverage Determination Team managing Part B claims. This team is accountable for managing major medical insurance claims. The team will work with coverage eligibility, submit claims, follow up with plan to obtain pre authorization,  obtain information and documents required for evaluation and transfer the case if financial assistance is needed. The Manager will manage  all aspects of the department functions, including personnel,  systems, initial and on going training and employee development, The Coverage Determination Manager Part B will also serve as the Training subject matter expert (SME) for the Operations team working in partnership with the Training & Development Manager.

Responsibilities include but are not limited to:

  • Holds self and others accountable for measurable high quality and  timely .

  • Ensure accurate and timely documentation by all employees providing access services (e.g  Perform insurance eligibility for patients, facilitate process for requesting Prior Authorizations,  etc.)

  • Develops/refines processes and procedures and ensures they are consistently applied across the Coverage Determination Part B  team

  • Leads Change – acts as a catalyst for organizational change and employee engagement.

  • Makes decisions that produce high quality results by applying technical knowledge, analyzing problems and calculating risks.

  • Partners with the Coverage Determination Part D and PAP Team when necessary. (e.g. Financial Assistance, etc.)

  • Assesses and analyses team performance, identifies performance gaps and provides feedback and coaching  

  • Responsible for leading a team through teaching, coaching and inspiring by fostering a sense of energy, ownership and a responsibility for the flawless execution of commercial excellence; engage in the selection and hiring process as needed.  

  • Administers company personnel policies and follows company staffing standards

  • Enforcing policies and procedures to include business standards, maintaining customer satisfaction levels  and improving quality of service.

  • Collaborates with key business partners on process and or operational improvements to enhance efficiency and effectiveness of Coverage Determination Part B team.

  • Monitoring and assessing staff’s compliance with the Company’s rules and procedures related to behavior with Patients and Co-workers, attendance, dress code, productivity standards and any other applicable instruction provided by Company’s management.

  • Performs other duties as assigned.

Required Qualifications :

Candidate Experience:

  • 2 years of leadership/people management experience is required

  • Prior experience working in health plan

  • Demonstrated track record of meeting/exceeding goals

  • Skilled at building relationships (e.g. Payers)

  • Prior experience working in Specialty Pharmacy preferred

  • Knowledge of Access and Reimbursement matters is preferred.

Technical Skills:

  • Knowledge of Microsoft Office programs (Word, Excel, Outlook) is required;

  • Knowledge of CPR+ (preferred)


  • Ability to communicate effectively in English and Spanish (preferred) .

Required Education:

  • Pharmacy Technician Associate Degree -Pharmacy license and registration

  • Bachelor’s degree in healthcare or business-related field (preferred)

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