Clinical Service Navigator - Pre-Auth & Documentation

MCS Puerto Rico; San Juan (PR); Hybrid; USD 32,000 - 52,000; Full time

Job summary

MCS Puerto Rico is seeking a healthcare administrative professional to receive, register, and forward requests for organizational determination and related clinical documentation for insured management. The role involves gatekeeping, evaluating documentation, and ensuring eligibility and pre-authorization processes are completed in line with regulations.

The incumbent will document pre-authorizations, coordinate with clinical areas, and support appeals when needed, while complying with all

Qualifications

• Associate’s Degree or 60–64 university credits in a health-related area and at least 1 year of related experience.
• Knowledge of Medical Terminology; CPT and ICD-10 codes are preferred.

Responsibilities

• Receives requests for organizational determination and related clinical documentation via fax, email, mail, or provider portal.
• Analyzes documentation to determine service type, urgency, and compliance with minimum requirements.
• Performs eligibility search and pre-authorization requirements and validates with provider.
• Documents pre-authorizations in insured files in accordance with regulations.
• Handles appeals and supports communication with Grievances and Appeals Unit.

Skills

Documentation analysis

Pre-authorization processing

Provider communication

Education

Associate’s Degree or 60–64 college credits in health-related area

At least 1 year of related experience

Job description

MCS Puerto Rico is seeking a healthcare administrative professional to receive, register, and forward requests for organizational determination and related clinical documentation for insured management. The role involves gatekeeping, evaluating documentation, and ensuring eligibility and pre-authorization processes are completed in line with regulations.

The incumbent will document pre-authorizations, coordinate with clinical areas, and support appeals when needed, while complying with all