Descripción de la oferta: Responsible for receiving and responding to calls from clients (insured parties, suppliers, pharmacies) related to the medication management process that involves making pre-authorizations by established guidelines and procedures, validating medication coverage (among other things), and documenting in the system the service provided for the company business lines. Participates with the pharmacy supervisor in tasks related to the validation of drug coverage, the search for clinical information to determine the substitution of a drug, the search for records of catastrophic patients, and the preparation of cases to determine if a drug is covered or not, among others, for the company business lines.

Responsabilidades: •Receive calls and faxes from Pharmacy Providers and Physicians related to the following situations: prescription refusals, eligibility issues, medication coverage issues, transmission issues, non-participating pharmacies or physicians, and pre-authorizations for the different company business lines. •Evaluate requests for coverage determinations, re-determinations, and reimbursements •Channels requests from pharmacy providers, physicians, and patients related to medication reimbursement, medication repetitions, medications by mail, etc. •Documents each Supplier request and actions taken in the corresponding systems. •Communicates with the Call Centers of the different pharmacy management medical offices, or infusion companies contracted by the company to resolve situations that cannot be handled locally by the department. •Guarantees that the patient can obtain their prescribed medications if it is within their reach by the clinical and administrative criteria established by the department. •Assigns codes in the electronic pharmacy systems and the company programs that allow the pharmacy provider(s) and physicians to complete the electronic transmission of claims. •Keeps pharmacy coverage information up to date about the company business lines, such as forms to use, copayments, regulatory letters, etc. •Participates in audit processes carried out by regulatory entities such as the Administration of Health Services and Against Addiction (ASES), and Centers for Medicare and Medicaid Services (CMS), among others. •Works on the resolution of cases (complaints or appeals) presented by agencies, such as OPP (Office of the Patient Advocate), Insurance Commissioner Office, and Legal Offices, among others. ADDITIONAL FUNCTIONS: • Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices. • May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.