• Evaluate requests received for Coverage Determination, properly classifies the request and handle it through the process distinguishing between coverage determination, grievances and appeals processes in accordance to the regulations and following Triple-S policies and procedures.• Gathers the necessary clinical information required to complete the evaluation of the case according HUM1 established criteria.• Contact physician, pharmacy and/or enrollee if further information is required to complete the evaluation and/or to obtain information necessary to make an appropriate clinical decision.• Deliver the information to Pharmacist so she or he can make a timely decision using the clinical criteria approved.• Documents all efforts for investigating, resolving and responding the cases in the system according the line of business.• Prepare letter to request information or to inform the final decision to pharmacy, physician and enrollee or authorized representative.• Offer orientation to pharmacy, physician and enrollee or authorized representative related to the Coverage Determination and Appeals processes.• Make calls to notify the status of the request to pharmacy, physician and/or enrollee or authorized representative.• Receive calls and inquiries from pharmacies and customer services department.• Make outbound calls to enrollee or authorized representative for adherence drugs to comply with CMS Stars Measures.• Responsible for ensuring the clinical accuracy of plan decision-making, including adherence to Medicare, Medicaid, Commercial and/or Federal and plan coverage criteria. This includes ensuring all Coverage Determination and Appeals involving medical necessity are made by an appropriate physician and/or pharmacist.• Identify and refer to the management any trends in complaints categories, area of opportunity and assist in the development of any action plan for immediate and effective reduction of complaints.• Collaborates with the operational metrics when required.• Perform any additional duties assigned by management.