Clinical Authorization & Documentation Specialist

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

Job summary

MCS Puerto Rico is seeking a detail-oriented specialist to handle organizational determinations and associated clinical documentation for insured management. The role requires processing requests via fax, email, regular mail, or provider portal, and performing eligibility checks and pre-authorizations in alignment with regulations.

You will document pre-authorization data, coordinate with clinical areas for complex cases, and ensure timely processing.

Qualifications

• Associate degree and/or 60-64 university credits in a health-related area.
• At least 1 year of related experience.
• Knowledge of Medical Terminology; CPT and ICD-10 Codes preferred.

Responsibilities

• Receives requests for organizational determination and related clinical documentation via fax, email, regular mail, or provider portal.
• Analyzes documentation to classify service type, urgency, and compliance with regulations.
• Performs eligibility search and pre-authorization requirements; validates information with providers.
• Documents pre-authorization in insured's file per regulations.
• Handles complex requests including US-based services and hospital discharges, coordinating with clinical areas.
• Monitors request times to maintain compliance and liaises with Grievances and Appeals Unit when needed.

Skills

Medical Terminology

Spanish (Intermediate)

English (Intermediate)

Education

Associate degree or 60-64 health-related credits

Tools

CPT/ICD-10 knowledge

Job description

MCS Puerto Rico is seeking a detail-oriented specialist to handle organizational determinations and associated clinical documentation for insured management. The role requires processing requests via fax, email, regular mail, or provider portal, and performing eligibility checks and pre-authorizations in alignment with regulations.

You will document pre-authorization data, coordinate with clinical areas for complex cases, and ensure timely processing.