Operations

We are the fuel that keeps Abarca’s engines running!

Our team works behind the scenes to deliver seamless and personalized healthcare. With expertise ranging across client and member services, clinical operations, network operations, quality assurance, and DarwinTM configuration and implementation, we’re ready to go Off Road to help Abarcans, clients, and partners meet their objectives.

WHAT WE DO

Service Operations

• Manage and support all customer service requests and operations for pharmacies, physicians, and beneficiaries/members.
• Address customer requests, payment status, manual reversal requests, benefit/eligibility support, provider portal support, and response to price appeals.
• Provide operational support to teams across Abarca to facilitate efficiency and repeatability in the delivery of services, and continuously review and update processes to ensure continued quality service.

Quality Assurance

• Monitor claims adjudication according to the client’s requirements.
• Document, communicate, and coordinate resolutions on claims issues identified through claims monitoring or reported by a client, member, or other sources.
• Perform configuration testing to ensure a successful go live.

Darwin™ Configuration

• Manage benefits, formulary, and pharmacy network requirements and implementations.
• Oversee the implementations of benefits, pharmacy network, pricing, formulary design, and system configurations as defined and documented by our client.
• Oversee the second-tier triage of operational issues as they arise, and analyze and identify solutions to resolve configuration setup issues, claims processing, and other operational gaps as needed.

Government Programs

• Ensures all metrics, goals, and tasks related to state and federal programs are completed and achieved per contractual agreements.
• Manage all processes and assure adherence to Centers for Medicare and Medicaid (CMS) requirements as well as state and federal regulations.
• Conduct research and identify and mitigate issues while maintaining consistent communication with all stakeholders within governments programs.