Claims Analyst I

MCS Puerto Rico; San Juan (PR); On-site; USD 40,000 - 55,000; Full time

Job summary

MCS Puerto Rico is seeking a claims processor to analyze and process professional and institutional claims. The role involves data entry, adjudication of payments, and issuing denials in line with policy requirements.

The position requires experience in data entry or medical billing within the healthcare insurance sector, plus a willingness to escalate complex cases to the next authorization level as needed.

Qualifications

• Bachelor's degree or higher is preferred with at least 6 months of data entry, medical billing, or provider call center experience.
• Prior data entry or billing experience in healthcare is favored.
• Proven ability to analyze and adjudicate claims within policy requirements.

Responsibilities

• Analyze and process simple to non-complex professional and institutional claims.
• Enter data, adjudicate payments, issue denials, and request additional information as needed.
• Process CMS-1500 and UB-04 claims according to required rules and timelines.
• Escalate claims beyond adjudication limits for higher authorization.
• Maintain productivity reports and accurate records in the inventory system.
• Comply with all company policies and applicable laws.

Skills

Data entry

Medical billing

Provider call center

Education

Bachelor's degree

Associate's degree

High school diploma or technical course

Job description

Regular

Non-Exempt

General Description

Analyzes and processes simple or non‑complex professional and institutional claims, including performing data entry, adjudicating payments, issuing denials, and requesting additional information, in accordance with applicable benefits, policy requirements, and within the adjudication authority limit established by current policies and procedures.

Essential Functions

• Analyzes claims that require support from other departments, particularly those that exceed the assigned adjudication limit and must be escalated to the next authorization level for further review and approval.
• Analyzes and corrects claim error reports identified within the claims processing system and related applications to ensure accuracy and compliance with established requirements.
• Processes claims while maintaining required financial accuracy and processing standards, following all current policies, procedures, and performance guidelines.
• Processes Centers for Medicare and Medicaid Services Form 1500 (CMS‑1500) and Uniform Billing Form 04 (UB‑04) claims based on the needs of the work unit, ensuring compliance with established processing rules, quality standards, and timeliness requirements.
• Performs data entry of claims, referrals, and Comprehensive Health Risk Assessment (CHRA) forms accurately and in accordance with established procedures.
• Cancels claims that have been processed within the work unit when required, ensuring correct documentation and adherence to internal protocols.
• Receives incoming claims, posts and records them in the unit’s inventory system, and archives them according to established departmental procedures.
• Maintains, updates, and adheres to their personal productivity report in alignment with departmental expectations and performance standards.

Additional Functions

• 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. At least six (6) months of experience in data entry, medical billing, or in a Provider Call Center in the Healthcare Insurance Industry is preferred.

OR

Education and Experience: Associate's Degree or at least sixty to sixty-four (60-64) approved college credits. At least one (1) year of experience in data entry, medical billing, or in a Provider Call Center in the Healthcare Insurance Industry is preferred.

OR

Education and Experience: High School Diploma or Technical Course. At least two (2) years of experience in data entry, medical billing, or in a Provider Call Center in the Healthcare Insurance Industry is preferred.

“Proven experience may be replaced by previously established requirements.”

Certifications / Licenses: Not required.

Other: N/A

Languages

Spanish – Intermediate (comprehensive, writing and verbal)

English – Basic (comprehensive, writing and verbal)

“We are an Equal Employment Opportunity Employer and take Aff….”