Clinical Operations Monitoring Analyst

MCS Puerto Rico; San Juan (PR); On-site; USD 65,000 - 95,000; Full time

Job summary

MCS Puerto Rico seeks a Clinical Operations Monitoring Analyst to oversee operational and regulatory processes, ensuring compliance with federal, state, contractual, and organizational requirements. The role supports excellence through data analysis, performance monitoring, reporting, and quality oversight.

You will analyze KPIs, develop recommendations, and provide timely reporting to leadership while supporting CAPs, audits, and cross-functional process improvements.

Qualifications

• Bachelor’s degree in Business Administration, Health Services Administration, or related areas.
• Minimum of three (3) years of experience supporting Medicare Advantage and Medicaid in health care operations, health insurance, regulatory compliance, grievances and appeals, claims administration, clinical operations, process improvement, reporting, quality management.

Responsibilities

• Monitor operational and regulatory processes to ensure compliance with applicable federal, state, contractual, and organizational requirements.
• Analyze performance metrics, KPIs, trends, and operational data to identify opportunities for improvement and mitigate risks.
• Develop, maintain, validate, and standardize operational and regulatory reports, dashboards, scorecards, and presentations for leadership and operational committees.
• Support corrective action plans (CAPs); perform root cause analyses and recommend corrective actions to improve performance and compliance.
• Monitor quality standards through audits, sampling methodologies, and process reviews to ensure accurate categorization, documentation, investigation, and timely resolution of cases.
• Identify concerns and escalate findings to management for appropriate action.
• Participate in regulatory audits, readiness activities, and data validation exercises as required.

Skills

Excel

Reporting tools

Operational software

Education

Bachelor’s degree in Business Administration, Health Services Administration, or related areas

Tools

Excel

Reporting tools

Job description

GENERAL DESCRIPTION

The Clinical Operations Monitoring Analyst is responsible for monitoring operational and regulatory processes to ensure compliance with applicable requirements, quality standards, and organizational policies. Supports operational excellence through data analysis, performance monitoring, reporting, process improvement initiatives, and quality oversight.

Regular
Exempt

GENERAL DESCRIPTION

The Clinical Operations Monitoring Analyst is responsible for monitoring operational and regulatory processes to ensure compliance with applicable requirements, quality standards, and organizational policies. Supports operational excellence through data analysis, performance monitoring, reporting, process improvement initiatives, and quality oversight. Analyzes key performance indicators (KPIs), identifies trends and risks, develops recommendations for improvement, and supports leadership decision-making through timely and accurate reporting.

ESSENTIAL FUNCTIONS

• Monitor operational and regulatory processes to ensure compliance with applicable federal, state, contractual, and organizational requirements. Serve as a subject matter resource regarding operational processes, reporting methodologies, and applicable regulatory requirements.
• Analyze performance metrics, key performance indicators (KPIs), trends, and operational data to identify opportunities for improvement and mitigate risks.
• Develop, maintain, validate, and standardize operational and regulatory reports, dashboards, scorecards, and presentations for leadership and operational committees.
• Support the development, implementation, and monitoring of corrective action plans (CAPs). Perform root cause analyses and recommend corrective actions to improve operational performance, quality outcomes, and regulatory compliance.
• Monitor quality standards through audits, sampling methodologies, and process reviews to ensure accurate categorization, documentation, investigation, and timely resolution of cases or transactions.
• Identify operational, compliance, and quality concerns and **escalate** findings to management for appropriate action.
• Support the monitoring of workload inventories, aging reports, turnaround times, and other performance indicators to ensure adherence to established service levels and regulatory requirements.
• Compile, analyze, and present statistical information to support operational reviews, audits, corrective action plans, and strategic initiatives.
• Collaborate with cross-functional teams to implement process improvements and operational efficiencies.
• Participate in regulatory audits, readiness activities, and data validation exercises as required.
• Support system enhancements, testing activities, and implementation initiatives impacting operational processes and reporting.
• Maintain documentation, reports, and records in accordance with established policies and procedures.
• Ensure all assigned responsibilities are completed within established quality standards, deadlines, and compliance requirements.
• 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, preferably in Business Administration, Health Services Administration, or related areas. Minimum of three (3) years of experience supporting MedicareAdvantage and Medicaid in health care operations, health insurance, regulatory compliance, grievances and appeals, claims administration, clinical operations, process improvement, reporting, quality management.

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

Certifications / Licenses: N/A

Other: Proficiency in Excel, reporting tools, and operational software is preferred.

Languages:
Spanish – Advanced (comprehensive, writing and verbal)
English – Intermediate (comprehensive, writing and verbal)

“We are an Equal Employment Opportunity Employer and take affirmative action to recruit Protected Veterans and Individuals with Disabilities.”