MCS Puerto Rico
Overview
GENERAL DESCRIPTION: Assists in investigating cases for resolution in compliance with the applicable regulations, guidelines, and contractual agreements. Participates in the implementation processes of the special networks, prompt payment, and directory complaints, which entails analyzing the operational impact, validations, and implementation of actions to maintain compliance with the directories in all their formats. Responsible for assessing, developing, and establishing an action plan for the identified points in any of these areas to ensure corporate processes. Regular Exempt GENERAL DESCRIPTION: Assists in investigating cases for resolution in compliance with the applicable regulations, guidelines, and contractual agreements. Participates in the implementation processes of the special networks, prompt payment, and directory complaints, which entails analyzing the operational impact, validations, and implementation of actions to maintain compliance with the directories in all their formats. Responsible for assessing, developing, and establishing an action plan for the identified points in any of these areas to ensure corporate processes.
Essential Functions
Provides support within the unit regarding timely resolutions of grievances and appeals filed by Addiuva according to the corresponding line of business.
Participates in the design and development of success indicators, operational metrics, and process flow analysis of the initiatives in their charge.
Conducts quality calls for Service, Credentialing, and Contracting units and reports findings to management for appropriate action. Develops reports on quality calls made to Service, Credentialing, and Contracting units to obtain metrics that lead to service satisfaction and complaint-handling evaluation.
Develops progress reports, analyzes data, and provides follow-up for the appropriate actions.
Creates files of the various monitoring efforts and submits them to the appropriate units as required.
Receives, analyzes, and seeks solutions to service issues from members and contracted providers, as applicable.
Refers, directs, and monitors configuration requests from providers, as applicable. This includes documentation in automated systems and/or other designated systems.
Maintains effective communication with the operational owners of each area, providers, and business partners on issues related to contractual agreements with the company.
Supports management in meetings with the company operational owners, providers, and business partners and ensure documentation of the agreements to obtain solutions and to provide continuity to what has been established.
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. At least two (2) years of experience in data management, development and production of reports, and analysis.
Certifications / Licenses:
N/A
Other:
Knowledge in Excel Intermediate and/or Advanced (vlookup, handling multiple reports and basic formulas). Knowledge of policies, procedures, regulations, and laws applicable to the Insurance Industry
Languages:
Spanish – Intermediate (comprehensive, writing and verbal); English – Intermediate (comprehensive, writing and verbal)
“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”
Other Details
Seniority level:
Entry level
Employment type:
Full-time
Job function:
Other
Industries:
Insurance
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GENERAL DESCRIPTION: Assists in investigating cases for resolution in compliance with the applicable regulations, guidelines, and contractual agreements. Participates in the implementation processes of the special networks, prompt payment, and directory complaints, which entails analyzing the operational impact, validations, and implementation of actions to maintain compliance with the directories in all their formats. Responsible for assessing, developing, and establishing an action plan for the identified points in any of these areas to ensure corporate processes. Regular Exempt GENERAL DESCRIPTION: Assists in investigating cases for resolution in compliance with the applicable regulations, guidelines, and contractual agreements. Participates in the implementation processes of the special networks, prompt payment, and directory complaints, which entails analyzing the operational impact, validations, and implementation of actions to maintain compliance with the directories in all their formats. Responsible for assessing, developing, and establishing an action plan for the identified points in any of these areas to ensure corporate processes.
Essential Functions
Provides support within the unit regarding timely resolutions of grievances and appeals filed by Addiuva according to the corresponding line of business.
Participates in the design and development of success indicators, operational metrics, and process flow analysis of the initiatives in their charge.
Conducts quality calls for Service, Credentialing, and Contracting units and reports findings to management for appropriate action. Develops reports on quality calls made to Service, Credentialing, and Contracting units to obtain metrics that lead to service satisfaction and complaint-handling evaluation.
Develops progress reports, analyzes data, and provides follow-up for the appropriate actions.
Creates files of the various monitoring efforts and submits them to the appropriate units as required.
Receives, analyzes, and seeks solutions to service issues from members and contracted providers, as applicable.
Refers, directs, and monitors configuration requests from providers, as applicable. This includes documentation in automated systems and/or other designated systems.
Maintains effective communication with the operational owners of each area, providers, and business partners on issues related to contractual agreements with the company.
Supports management in meetings with the company operational owners, providers, and business partners and ensure documentation of the agreements to obtain solutions and to provide continuity to what has been established.
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. At least two (2) years of experience in data management, development and production of reports, and analysis.
Certifications / Licenses:
N/A
Other:
Knowledge in Excel Intermediate and/or Advanced (vlookup, handling multiple reports and basic formulas). Knowledge of policies, procedures, regulations, and laws applicable to the Insurance Industry
Languages:
Spanish – Intermediate (comprehensive, writing and verbal); English – Intermediate (comprehensive, writing and verbal)
“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”
Other Details
Seniority level:
Entry level
Employment type:
Full-time
Job function:
Other
Industries:
Insurance
Referrals increase your chances of interviewing at MCS Puerto Rico by 2x
We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
#J-18808-Ljbffr