Clinical Authorization & Documentation Specialist

MCS Puerto Rico; San Juan (PR); On-site; USD 36,000 - 46,000; Full time

Job summary

MCS Puerto Rico is seeking a documentation and authorization specialist to manage pre-service organizational determinations and related clinical records. You will classify and route documents, verify information, and coordinate with clinical areas to ensure timely processing.

The role requires knowledge of medical terminology and CPT/ICD-10 codes, with Spanish and English at an intermediate level. You will liaise with provider portals and various centers to streamline authorizations.

Qualifications

• Associate degree or 60 credits in health-related studies with at least 1 year of related experience.
• Knowledge of Medical Terminology; CPT and ICD-10 codes are preferred.
• Bilingual capability in Spanish and English (intermediate level).

Responsibilities

• Receive requests via fax, email, mail, or provider portal for pre-service organizational determination.
• Classify and distribute documentation to technicians according to operations needs.
• Analyze documentation and medical orders to determine service type and urgency.
• Perform eligibility search and pre-authorization for requested services.
• Document pre-authorization in the insured's file per applicable regulations.
• Handle complex requests including US-based services, durable medical equipment, and hospital discharge.
• Notify insured/provider after service authorization is completed.
• Monitor request times to maintain compliance percentages for authorizations.
• Assist with appeals in coordination with the Grievances and Appeals Unit.
• Work with Call Center queries to modify pre-authorizations or verbal requests.
• Inform Providers Department about payment agreement letters for non-participating providers.
• May carry out other duties as assigned.

Skills

Medical terminology

Education

Associate degree / 60 credits in health

Job description

MCS Puerto Rico is seeking a documentation and authorization specialist to manage pre-service organizational determinations and related clinical records. You will classify and route documents, verify information, and coordinate with clinical areas to ensure timely processing.

The role requires knowledge of medical terminology and CPT/ICD-10 codes, with Spanish and English at an intermediate level. You will liaise with provider portals and various centers to streamline authorizations.