Claims Specialist

MCS Puerto Rico; San Juan (PR); On-site; USD 42,000 - 68,000; Full time

Job summary

MCS Puerto Rico in San Juan seeks a Claims Analyst to evaluate medical and life insurance claims and ensure adjudication aligns with policy rules and regulatory standards. The role focuses on efficiency, accuracy, and collaboration with other departments.

The position requires a Bachelor's or Associate degree with relevant claims experience, strong Excel/Office skills, and knowledge of industry quality parameters. Fluent communication in English and Spanish is helpful for coordination.

Qualifications

• Bachelor's degree or equivalent with claims processing experience.
• Associate's degree with 4+ years in the industry and processing knowledge.
• Familiarity with Excel, Word, Access, and PowerPoint.
• Knowledge of industry quality parameters and regulations.

Responsibilities

• Evaluate handling, processing, and payment of medical and/or life insurance claims by reviewing policyholder benefits and contracts.
• Ensure adherence to standards and regulatory guidelines during adjudication.
• Analyze complex COB, reimbursements, adjustments, and recoveries within policies.
• Verify CMS and Medicare policies and monitor regulatory standards for the department.
• Maintain up-to-date Claims Policies and Procedures Manual.
• Coordinate with other departments to resolve referred claims and provide technical assistance.
• Investigate issues with electronic claims transmissions and assess audit results for improvements.
• Prepare management reports and assist with adjudication quality reviews.

Education

Bachelor's Degree

Associate's Degree / 60-64 credits

Tools

Excel

Word

Access

PowerPoint

Job description

GENERAL DESCRIPTION

Evaluates the handling, processing, and/or payment of medical and/or life insurance claims to seek efficiency in the claim adjudication processes of each of the analysts, according to the parameters established in the unit, and seeks continuous improvement and compliance with corporate results. Makes referrals of findings to claims supervisors and/or other departments that relate directly or indirectly to the processes evaluated and/or areas of improvement identified.

Regular
Exempt

ESSENTIAL FUNCTIONS

• Evaluate the handling, processing, and/or payment of medical and/or life insurance claims by reviewing the policyholders' benefits, business rules, contracts of providers, service fees, and other applicable sources of information to determine the appropriate handling performed by each of the claim analysts at the time of adjudication.
• Determines if the claims analyst applied correctly the standards established in the company, the health industry, and/or regulatory agencies at the time of the adjudication to determine compliance of the operational processes with the guidelines established in these that impact the payment of claims.
• Analyzes and adjudicates complex claims of Coverage of Benefits (COB), sampling, United States claims, reimbursement, complaints, all kinds of adjustments and recoveries, reinsurance, and life insurance to the maximum indicated in the Policies and Procedures (P&P’s).
• Verifies Medicare policies and does appropriate research at the Centers for Medicare and Medicaid (CMS), as well as other policies established by other regulatory agencies. Monitors Medicare compliance standards and regulatory agencies for the department.
• Keep the Claims Policies and Procedures Manual for all business lines up to date with changes in procedures and policies.
• Coordinates with other departments to resolve referred claims for evaluation and payment determinations. Provides technical assistance concerning the claim adjudication process to other departments when necessary.
• Evaluate and request new codes or the deactivation of codes and/or changes in their status (deny, warning, among others).
• Investigate and report any issues with electronic claims transmissions to the Delegated Functions Unit of the Operations Quality Department. Evaluate the results of audits that the Operations Quality Department carries out, discuss the results with the management, and identify areas for improvement.
• Performs BETA testing of changes to payment rules, new Medicare policies, changes to Fee Schedule, Prices, and contracting of providers, among others. Performs Fee Schedule and Benefit Screen Analyses to establish process guides related to provider and benefit assembling.
• Discuss with management the individual results of each analyst of the analyses carried out to identify areas of improvement, such as but not limited to assembly corrections in the systems used, modification and standardization of processes, retraining of personnel, and application of payment rules. Prepares reports requested by the management to measure process efficiency and assists with guidance on reviewing the adjudication quality of sample claims by each analyst.
• Analyze providers' contracts to determine if the payment applicable to the services was correct.
• Analyze audit findings to create required reports and presentations and complete the closing of provider audits.
• 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 two (2) years of experience in the industry, including analytical and statistical knowledge, and claims processing.

OR

Education and Experience: Associate's Degree or sixty to sixty-four (60-64) approved college credits. At least four (4) years of experience in the industry, including analytical and statistical knowledge, and claims processing.

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

Certifications / Licenses: N/A

Other: Familiarity with industry-standard quality parameters. Knowledge of process monitoring and evaluation (desirable). Knowledge of Excel, Word, Access, and/or PowerPoint. knowledge of programs, policies, procedures, regulations, and laws applicable to the industry.

Languages

Spanish – Intermediate (comprehensive, writing, and verbal)
English – Intermediate (comprehensive, writing, and verbal)

We are an Equal Employment Opportunity Employer and take Aff