MCS Puerto Rico
General Description
Receive the Grievances, Pre‑Service Appeals, Post‑Service Appeals, Payment Disputes, Payment Appeals, and Administrative Organizational Determinations (AOD) filed by Providers and members, as applicable. Responsible for filling and assigning cases to the Specialists in accordance with established time frames.
Essential Functions
Categorizes and registers in the electronic platforms the grievances, pre‑service or post‑service appeals received through various sources for both Line of Business, MCS Life, and MCS Classicare.
Registers the grievances received from the Office of the Patient Advocate and the Late Enrolment Penalty (LEP) Reconsiderations in the system.
Coordinates calls to members, Providers, or company staff (including emails) if required to validate the allegations on grievances and/or appeals, for proper categorization and referral in accordance with Regulation. If the allegation represents more than one issue, proceed to register the grievances separately according to the category, based on the Regulation and Policies & Procedures of the Unit.
Receives calls from members and/or Providers and refers them according to procedure.
Responsible for handling calls received through the teletypewriter (TTY), delegated electronic line (telephone line for hearing impaired persons).
Validates the member's contract in the eligibility system, prints the details of eligibility dates and address, and attaches this information to the file in the system.
Assigns grievances, pre‑service appeals or post‑service appeals to the Specialists or Senior Specialists.
If required, provide data for Grievances and Appeals reports in compliance with time frames and as required by Regulatory Agencies and/or other Departments or Units of the company.
In conjunction with the Team Leader manages the filter of Grievances, Appeals and AOD’s received in the Unit to safeguard that all cases are properly identified, analyze, registered, as applicable.
Provides support in the mailing process to members and/or Providers, as needed and to comply with regulatory time frames.
Prepares and mails to members or Providers the Acknowledgment Notice, the Request for AOR Form Notice or Withdrawal Notice.
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: Associate's Degree or at least sixty to sixty‑four (60‑64) approved college credits equivalent to two (2) years of studies. Minimum of one (1) year of related experience in auditing, research, and/or customer/provider service.
Certifications / Licenses: N/A
Other: Knowledge of PMHS, Front End, Grievance and Appeals, preferable.
Languages: Spanish – Intermediate (writing, conversation, and comprehension); English – Intermediate (writing, conversation, and comprehension).
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
Essential Functions
Categorizes and registers in the electronic platforms the grievances, pre‑service or post‑service appeals received through various sources for both Line of Business, MCS Life, and MCS Classicare.
Registers the grievances received from the Office of the Patient Advocate and the Late Enrolment Penalty (LEP) Reconsiderations in the system.
Coordinates calls to members, Providers, or company staff (including emails) if required to validate the allegations on grievances and/or appeals, for proper categorization and referral in accordance with Regulation. If the allegation represents more than one issue, proceed to register the grievances separately according to the category, based on the Regulation and Policies & Procedures of the Unit.
Receives calls from members and/or Providers and refers them according to procedure.
Responsible for handling calls received through the teletypewriter (TTY), delegated electronic line (telephone line for hearing impaired persons).
Validates the member's contract in the eligibility system, prints the details of eligibility dates and address, and attaches this information to the file in the system.
Assigns grievances, pre‑service appeals or post‑service appeals to the Specialists or Senior Specialists.
If required, provide data for Grievances and Appeals reports in compliance with time frames and as required by Regulatory Agencies and/or other Departments or Units of the company.
In conjunction with the Team Leader manages the filter of Grievances, Appeals and AOD’s received in the Unit to safeguard that all cases are properly identified, analyze, registered, as applicable.
Provides support in the mailing process to members and/or Providers, as needed and to comply with regulatory time frames.
Prepares and mails to members or Providers the Acknowledgment Notice, the Request for AOR Form Notice or Withdrawal Notice.
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: Associate's Degree or at least sixty to sixty‑four (60‑64) approved college credits equivalent to two (2) years of studies. Minimum of one (1) year of related experience in auditing, research, and/or customer/provider service.
Certifications / Licenses: N/A
Other: Knowledge of PMHS, Front End, Grievance and Appeals, preferable.
Languages: Spanish – Intermediate (writing, conversation, and comprehension); English – Intermediate (writing, conversation, and comprehension).
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