Compliance & Workflow Supervisor - Org Determination

MCS Puerto Rico; San Juan (PR); On-site; USD 60,000 - 90,000; Full time

Job summary

MCS Puerto Rico is seeking a Healthcare Operations Analyst to monitor operational activities related to pre-service organizational determination requests and clinical documentation, ensuring compliance with CMS regulations and internal standards. You will oversee audits, workflows, and documentation accuracy within the unit, focusing on timeliness and efficiency.

The role requires understanding of ICD-10/CPT codes, plus 3+ years in health services and at least 1 year of supervision.

Qualifications

• Education and Experience: Bachelor's degree in Health Services Administration or health-related areas; at least 3 years in a health service position; at least 1 year supervising staff.
• Certifications / Licenses: N/A
• Other: Knowledge of ICD-10 and CPT codes.

Responsibilities

• Monitor and audit services related to the Organizational Determination process for CMS and regulatory compliance.
• Ensure compliance with regulatory timeframes and operational efficiency.
• Analyze root causes and trends from turnaround time reports to develop operational strategies.
• Oversee daily backlogs and aging of requests with team leaders to identify non-compliance and plan actions.
• Ensure workflows for initial evaluation, eligibility validation, pre-authorization, and proper documentation are followed and timely distributed.
• Conduct random sample audits to identify findings early.
• Maintain and monitor metrics and data entry quality across reports.
• Oversee work plans and daily priorities for supervised team leaders.
• Develop corrective action plans based on root causes of non-compliance.
• Maintain documentation for easy root cause analysis and reinforcements or retraining as needed.
• Perform retraining and process reinforcement as required.

Skills

Regulatory compliance

Auditing

Root cause analysis

Process optimization

Documentation

Team supervision

Spanish (Intermediate)

English (Intermediate)

Education

Bachelor's degree in Health Services Administration

3+ years experience in health service position

1+ year supervising staff

Knowledge of ICD-10 and CPT codes

Job description

MCS Puerto Rico is seeking a Healthcare Operations Analyst to monitor operational activities related to pre-service organizational determination requests and clinical documentation, ensuring compliance with CMS regulations and internal standards. You will oversee audits, workflows, and documentation accuracy within the unit, focusing on timeliness and efficiency.

The role requires understanding of ICD-10/CPT codes, plus 3+ years in health services and at least 1 year of supervision.