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Coverage Determination Jobs (NOW HIRING)

SlateRx

Clinical Coordinator

Las Vegas, NV · Remote

$23 - $26/hr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Configure authorized coverage determination and appeal outcomes in the adjudication system after completion of review and decision by the pharmacist or client. * Handle inbound phone calls from ...

SlateRx

Clinical Coordinator

Las Vegas, NV · On-site +1

$23 - $26/hr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Configure authorized coverage determination and appeal outcomes in the adjudication system after completion of review and decision by the pharmacist or client. * Handle inbound phone calls from ...

Healthcare Support Staffing

Pharmacy Technician

Orlando, FL

$13 - $14.50/hr

  • Medical

  • Dental

  • Vision

Track and triage all coverage determination requests for prior authorizations and Medicare Part D recipients Track and triage coverage determination requests submitted from providers and determine if ...

Retina Consultants

Billing Specialist

Greenville, SC · On-site

$17.25 - $23.25/hr

  • Medical

  • Life

  • Retirement

  • PTO

Stay informed of Medicare Local Coverage Determination and National Coverage Determination as related to our services * Post insurance and patient payments as needed * Manage patient financial ...

Actalent

Remote Pharmacy Technician

$18 - $21.75/hr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Evaluate coverage determination requests using established clinical and plan criteria and document clear approval or denial decisions. * Enter all decisions and related information accurately into ...

Actalent

Remote Pharmacy Technician

$18 - $21.75/hr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Evaluate coverage determination requests using established clinical and plan criteria and document clear approval or denial decisions. * Enter all decisions and related information accurately into ...

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All JobsCoverage Determination Jobs

Coverage Determination information

See salary details

$54.5K

$96.2K

$139K

How much do coverage determination jobs pay per year?

As of Aug 18, 2026, the average yearly pay for coverage determination in the United States is $96,169.00, according to ZipRecruiter salary data. Most workers in this role earn between $81,000.00 and $109,500.00 per year, depending on experience, location, and employer.

What is a coverage determination?

A Coverage Determination is a decision made by a health insurance company, usually Medicare Part D or Medicare Advantage plans, regarding whether a specific prescription drug or service will be covered for a member. Members or their healthcare providers can request a coverage determination if they need a medication that is not typically covered, or if they need an exception to the plan's rules. The process involves reviewing the member's medical necessity and the plan's formulary guidelines before issuing an approval or denial.

What are the key skills and qualifications needed to thrive as a coverage determination specialist, and why are they important?

To thrive as a Coverage Determination Specialist, you need a solid understanding of insurance policies, pharmacy benefit management, and medical terminology, often supported by a relevant degree or healthcare experience. Familiarity with claims processing software, Medicare Part D systems, and regulatory guidelines is essential. Strong attention to detail, analytical thinking, and effective communication skills help in reviewing requests and coordinating with healthcare providers. These skills ensure accurate and timely coverage decisions, improving patient care and maintaining compliance with industry standards.

What are some typical challenges faced in a coverage determination role, and how can they be managed effectively?

Professionals in Coverage Determination often encounter challenges such as navigating complex insurance policies, ensuring compliance with regulations, and balancing timely responses with thorough case reviews. Staying up-to-date on changing healthcare laws and payer requirements is crucial, as is maintaining clear communication with providers, members, and team members. Developing strong organizational skills and leveraging available technology can help manage workloads efficiently and ensure accurate determinations.

What is the difference between Coverage Determination vs Claims Processor?

AspectCoverage DeterminationClaims Processor
Required credentialsTypically requires healthcare or insurance-related certificationsOften requires administrative or clerical experience
Work environmentHealthcare insurance companies, government agenciesInsurance companies, healthcare providers, third-party administrators
Employer and industry usageUsed in health insurance to decide coverage eligibilityUsed to process and review insurance claims for payment

Coverage Determination involves evaluating whether a healthcare service or item is covered under an insurance policy, often requiring detailed review of medical necessity and policy terms. Claims Processors handle the administrative task of reviewing submitted claims, ensuring accuracy, and facilitating payment. While both roles are integral to insurance operations, Coverage Determination focuses on eligibility, whereas Claims Processors manage claim processing and reimbursement.

More about Coverage Determination jobs

What job categories do people searching Coverage Determination jobs look for?

The top searched job categories for Coverage Determination jobs are:

Coverage Determination jobs near you
Infographic showing various Coverage Determination job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 84% Full Time, 10% Part Time, and 5% Contract. Highlights an 79% Physical, 1% Hybrid, and 20% Remote job distribution, with an average salary of $96,169 per year, or $46.2 per hour.

Coverage Determination Representative

BioPlus Health

Altamonte Springs, FL • On-site

$16 - $20.25/hr

Other

Medical, Retirement

Re-posted 14 days ago

Job description

Coverage Determination Representative

As one of the largest and most respected specialty pharmacies, BioPlus creates a meaningful difference to our patients, prescribers, payers, and pharmaceutical partners.

Our 2 - Hour Patient Acceptance Guarantee gives a quick response to prescribers and patients for critical, time - sensitive treatments. As we continue to grow, we need exceptionally talented, bright, and driven people. If you would like to help us continue to be the innovative leader in our industry, this is your chance to join our team.

Job Description

The Coverage Determination Rep I is responsible for gathering all information required on an authorization, completing, and submitting the authorization form to insurance company and for all follow up phone calls and documentation of these authorizations.

Responsibilities

  • Obtain prior authorizations; initiate requests, track progress, and expedite responses from insurance carriers and other payers.
  • Review prescription for accuracy of prescribed treatment regimen prior to submission of authorization.
  • Gather all necessary information from prescriber offices to complete authorization forms.
  • Notifying appropriate staff of approved/denied medications.
  • Process/reverse online claims to confirm authorization outcome.
  • Completes status check with insurance company regarding receipt and outcome of prior authorization.
  • Perform call to prescriber office for status of authorization or request for additional information.
  • Responsible for all documentation of authorization statuses into CPR+ progress notes.
  • Update sales staff with pertinent information.
  • Participate and perform other duties as assigned by leadership

Skills & Abilities

  • Positive Attitude
  • Professional appearance
  • Work cooperatively and be a liaison between departments when needed
  • Knowledge of standard medical terminology and pharmacy prior authorization and appeal/denial processes desired
  • Demonstrate excellent oral, presentation, and written communication skills
  • Demonstrate proficiency in the use of MS Office software, which includes Excel, Word, and Outlook
  • Demonstrate the BioPlus C.A.R.T. values.

Qualifications

  • High School Diploma or Equivalent.
  • At least 1 year experience working with pharmacy prior authorizations, or pharmacy billing.
  • Specialty pharmacy experience preferred.
Additional Information

BioPlus offers competitive compensation packages including health care, 401(k), growth potential, and a challenging and exciting work environment.

BioPlus is an Equal Opportunity Employer

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