Clinical Services Technician

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

Job Description

Responsible for receiving, registering, and forwarding requests for organizational determination and/or any associated clinical documentation or documentation for the clinical management of the insured. Works with the authorizations of services already predetermined through the automatic process using the benefits criteria and in compliance with the applicable organizational determination regulation and universes, reports, and the applicable regulation.

Job Type

Regular – Non-Exempt

Essential Functions

• Receives via facsimile, email, regular mail, or provider portal the requests for pre‑service organizational determination and/or any clinical documentation for insured management. Performs gatekeeper roles according to operational needs to support group leaders in classifying the documentation received and distributing the rest to the technicians.
• Assertively and exhaustively manages and analyzes the documentation received, including medical orders to establish the type of service requested, the level of urgency and ensure that it meets the minimum required. Making sure to evaluate the expiration date of the faxes in conjunction with the group leader.
• Performs the eligibility search and the Pre‑authorization requirement of the requested service. Validate information with the provider to complete the process.
• Documents the pre‑authorization in the insured's file, entering the data that complies with the requirements established in reports and/or applicable regulations.
• Handles complex requests such as services in the US, durable medical equipment, and hospital discharge requiring additional interventions in direct communication with clinical areas to facilitate the process.
• Performs the authorization of services already predetermined through the automatic process using the benefits criterion in compliance with the applicable regulation, including notification to the insured/provider.
• Monitors assigned request times to maintain the compliance percentage for both authorizations and area assemblies.
• Appropriately handles appeals requests requiring communication and service alliances with the Grievances and Appeals Unit, knowledgeable about the appeal scenarios and the impact on STARS.
• Works with the queries and requests referred from the Call Center and Service Centers to facilitate the service either by modifying the Pre-authorizations or handling the verbal requests of the insured.
• Inform the Providers Department of the services that require payment agreement letters for the additional non-participating providers. Coordinates the configuration of non-existent providers in the tools.
• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
• 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.

Minimum Qualifications

Education and Experience: Associate's Degree and/or sixteen (60) university credits equivalent to two (2) years of studies in health related. At least one (1) year of related experience.

Proven experience may be replaced by previously established requirements.

Certifications/Licenses: N/A

Other: Knowledge of Medical Terminology. CPT and ICD-10 Codes are preferred.

Languages

Spanish – Intermediate (conversational, writing, and comprehension)

English – Intermediate (conversational, writing, and comprehension)

We are an Equal Employment Opportunity Employer and take affirmative action to recruit protected veterans and individuals with disabilities.