MCS Puerto Rico
Contract Implementation Analyst – MCS Puerto Rico
Responsible for analyzing, interpreting, determining, and configuring the parameters of contractual agreements for all participants and non-participants among providers (both Professional and Institutional) within both lines of business. Ensures accurate claims payments, updates fee schedules, and makes changes to demographic data.
Position type: Regular, Exempt.
Essential Functions
Evaluate and configure demographic information for providers with new contracts and update existing information in the appropriate system for all business segments.
Create and configure changes in all necessary fields within the system and their pop-up additional screens according to special provider needs for the correct processing and management of the submitted transactions.
Analyze and translate the provider’s contract requirements and changes. Recommend creating a new fee schedule if necessary and configuring the provider payment lines. Review fee schedules upon completion of facility and provider contract re‑negotiations and ensure that they are properly assigned.
Investigate requests for non‑processable claims that have been referred by other departments due to configuration issues, electronic claims upload errors, and the configuration of participating and non‑participating providers. If no changes are required, inform the appropriate area of the results of the analysis and validation, and outline the next steps. If any changes are made to the system, oversee the reopening and adjudication of the transactions to verify that the changes were implemented correctly. The system will process these transactions following contracts and requirements.
Create in Excel all provider data input to run the mass configuration changes for either script or robot functionalities. Execute Script or Robot functionalities if applied, for mass configuration changes. Also, validate if the changes were posted, or rejected, and if there are rejections, evaluate the reasons and make the necessary changes.
Responsible for identifying the dental provider’s issues that may affect claims processing within the vendor. If any changes are necessary, make the appropriate corrections in the provider system. Ensure that data flows accurately to the entity through the provider file and confirms the provider and vendor status through the dental claims business partner portal back to the entity.
Set up in the system the different options for the direct deposit information requested by the provider and modify and configure all the Withholding Relief percentages as determined by the Puerto Rico Treasury Department for each calendar year in the system.
Configure the payment type changes to process the special runs payments for different vendors as requested by the Financial Department.
Configure in the system the beneficiary demographic information to process the MCS Life Insurance payments.
Identify the Independent Physician Association (IPA) and the Provider Organization Identification (PORG) IDs, connecting both to all related providers to ensure accurate capitation payments.
Performs searches through regulators’ portals to all non‑contracted providers to validate demographics and exclusions established by the Office of Inspector General (OIG), Preclusion List & Sam to determine if the company can do business and process payments to the provider. If the provider is active in any of these portals or lists, it is identified in the core system with a hold code to avoid any compliance or financial risk.
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.
Minimum Qualifications
Education and Experience:
Bachelor’s Degree preferably in Business Administration or related areas. At least two (2) years of experience in provider contract implementation, claims processing or adjustment, provider contracting, and service in the Health Insurance Industry.
Certifications / Licenses:
N/A.
Other:
Basic knowledge of database administration. Intermediate knowledge of Excel. Knowledge of standard Healthcare Industry procedure codes such as Current Procedural Terminology (CPT), Revenue Codes, and Healthcare Common Procedure Coding System (HCPCS).
Languages:
Spanish – Intermediate (comprehensive, writing and verbal); English – Intermediate (comprehensive, writing and verbal).
“Proven experience may be replaced by previously established requirements.”
Equal Opportunity Statement “Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento.”
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Position type: Regular, Exempt.
Essential Functions
Evaluate and configure demographic information for providers with new contracts and update existing information in the appropriate system for all business segments.
Create and configure changes in all necessary fields within the system and their pop-up additional screens according to special provider needs for the correct processing and management of the submitted transactions.
Analyze and translate the provider’s contract requirements and changes. Recommend creating a new fee schedule if necessary and configuring the provider payment lines. Review fee schedules upon completion of facility and provider contract re‑negotiations and ensure that they are properly assigned.
Investigate requests for non‑processable claims that have been referred by other departments due to configuration issues, electronic claims upload errors, and the configuration of participating and non‑participating providers. If no changes are required, inform the appropriate area of the results of the analysis and validation, and outline the next steps. If any changes are made to the system, oversee the reopening and adjudication of the transactions to verify that the changes were implemented correctly. The system will process these transactions following contracts and requirements.
Create in Excel all provider data input to run the mass configuration changes for either script or robot functionalities. Execute Script or Robot functionalities if applied, for mass configuration changes. Also, validate if the changes were posted, or rejected, and if there are rejections, evaluate the reasons and make the necessary changes.
Responsible for identifying the dental provider’s issues that may affect claims processing within the vendor. If any changes are necessary, make the appropriate corrections in the provider system. Ensure that data flows accurately to the entity through the provider file and confirms the provider and vendor status through the dental claims business partner portal back to the entity.
Set up in the system the different options for the direct deposit information requested by the provider and modify and configure all the Withholding Relief percentages as determined by the Puerto Rico Treasury Department for each calendar year in the system.
Configure the payment type changes to process the special runs payments for different vendors as requested by the Financial Department.
Configure in the system the beneficiary demographic information to process the MCS Life Insurance payments.
Identify the Independent Physician Association (IPA) and the Provider Organization Identification (PORG) IDs, connecting both to all related providers to ensure accurate capitation payments.
Performs searches through regulators’ portals to all non‑contracted providers to validate demographics and exclusions established by the Office of Inspector General (OIG), Preclusion List & Sam to determine if the company can do business and process payments to the provider. If the provider is active in any of these portals or lists, it is identified in the core system with a hold code to avoid any compliance or financial risk.
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.
Minimum Qualifications
Education and Experience:
Bachelor’s Degree preferably in Business Administration or related areas. At least two (2) years of experience in provider contract implementation, claims processing or adjustment, provider contracting, and service in the Health Insurance Industry.
Certifications / Licenses:
N/A.
Other:
Basic knowledge of database administration. Intermediate knowledge of Excel. Knowledge of standard Healthcare Industry procedure codes such as Current Procedural Terminology (CPT), Revenue Codes, and Healthcare Common Procedure Coding System (HCPCS).
Languages:
Spanish – Intermediate (comprehensive, writing and verbal); English – Intermediate (comprehensive, writing and verbal).
“Proven experience may be replaced by previously established requirements.”
Equal Opportunity Statement “Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento.”
#J-18808-Ljbffr