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…
Our Operational Performance team is #All-In on centralizing data to dive through and study as they work on improving operations at Abarca. The Operational Performance team tracks goals and metrics to proactively manage shortfalls and ensure we continuously set and reach the highest standards. That’s why performance is part of their name as they help drive both scalability and efficiency across the board!
As an Issue Management Analyst, you will collaborate with other key functional areas to ensure the quality and integrity of the claims processing system by being responsible for identifying, analyzing, documenting, and reporting issues that may impact client or members. You will support the timely performance and completion of all issue management activities of the organization; specifically, conducting the investigation and documentation of the description, root cause, corrective actions, preventive measures, and reporting of claims processing issues. We count on you to make recommendations for corrective actions and process improvements based on documentary and report reviews and to ensure proper monitoring of post-corrective actions to avoid reoccurrence.
The fundamentals for the job…
- Contribute tactical and strategic initiatives to improve oversight and issue management, processes, tools, and reporting capabilities.
- Participate in the preparation for CMS, client or internal audits as well as follow through on any corrective actions requiring quality assurance.
- Contribute to the implementation and continuous development of any systems and/or tools used to support Issue Management activities.
- Interpret Darwin RxEngine and Client Platform releases documentation and participate of the Regulatory and Compliance Management (RCM) committee to thoroughly understand any change or new functionality that could impact compliance with CMS, state regulations and/or benefit design, and define and implement necessary oversight processes.
- Understand, collaborate, and participate in the development of new ideas and requirements to resolve system’s issues and improve current systems based on oversight results.
- Responsible for collaborating on the development and maintenance of Issue Management policies and procedures.
- Lead the company-wide issue management process and committee.
What we expect of you:
The bold requirements…
- Associate’s Degree or Bachelor’s Degree in Science, Management, Business, or related area. (In lieu of a degree, equivalent relevant work experience may be considered.)
- 1+ years of experience with pharmacy claims and adjudications
- Experience in pharmacy benefit management, healthcare and/or non-retail pharmacy setting
- Experience with data management, analysis, and reporting
- Experience with quality, audit, controls, and business process improvements.
- Experience with Microsoft Excel for reporting and analytical functions.
- Experience in using critical thinking, negotiation, and strategic thinking within an issue management context.
- Excellent oral and written communication skills.
- Bilingual fluency in English and Spanish is required.
- We are proud to offer a flexible hybrid work model which will require certain on-site work days (Puerto Rico Location Only)
Nice to have…
- Project Management Certification such as in PMP, Agile or others.
- Experience with SQL.
- 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.