Clinical Appeals & Determinations Specialist

MCS Puerto Rico; San Juan (PR); On-site; USD 45,000 - 65,000; Full time

Job summary

MCS Puerto Rico is seeking a clinical nurse to evaluate pre-service and reconsideration requests. The candidate will conduct thorough clinical analyses and provide administrative support to ensure timely decision-making.

This role requires at least two years of clinical experience and a Bachelor's Degree in Nursing. Proficiency in Spanish and English will be an asset. Join us in delivering quality healthcare services while adhering to regulations and policies.

Qualifications

• Minimum of two (2) years of experience in clinical areas.
• Valid License and Registration of Nurse in Puerto Rico required.
• Intermediate proficiency in Spanish and English.

Responsibilities

• Evaluate pre-service and appeals requests according to regulations.
• Perform clinical analyses of reconsiderations submitted to MCS.
• Conduct outreach for clinical information necessary for evaluation.

Skills

Clinical analysis

Critical thinking

Provider communication

Clinical documentation

Regulatory compliance

Education

Bachelor's Degree in Nursing

Job description

MCS Puerto Rico is seeking a clinical nurse to evaluate pre-service and reconsideration requests. The candidate will conduct thorough clinical analyses and provide administrative support to ensure timely decision-making.

This role requires at least two years of clinical experience and a Bachelor's Degree in Nursing. Proficiency in Spanish and English will be an asset. Join us in delivering quality healthcare services while adhering to regulations and policies.