Grievances & Appeals Expert

MCS Puerto Rico; San Juan (PR); On-site; USD 42,000 - 64,000; Full time

Job summary

MCS Puerto Rico is seeking an analyst to analyze, investigate, and resolve grievances, dental pre-service, and payment appeals. You will collaborate with multiple departments, ensure proper documentation in English, and manage case files to meet regulatory timeliness.

This role emphasizes compliance with CMS and OIC rules and involves coordinating with independent review entities when required. The position requires a Bachelor's or an Associate’s degree with several years in research or auditing

Qualifications

• Bachelor’s degree with 3 years in research, auditing, or client/provider service in health insurance.
• Associate’s degree with 5 years in research, auditing, or client/provider service in health insurance.
• Knowledge in Beacon and PMHS preferred.
• Languages: Spanish and English – Intermediate.

Responsibilities

• Analyze, investigate, resolve, and respond to grievances, dental pre-service, and payment appeals.
• Collaborate with other departments and reviewers; validate responses and document root causes.
• Document cases in English; manage files for CMS IRE and OIC processes; monitor timeliness.
• Ensure compliance with regulations; handle second level appeals as required.

Education

Bachelor’s degree in Business Administration, Finance, Social Sciences, or Criminal Justice

Associate’s degree or 60 approved university credits

Job description

MCS Puerto Rico is seeking an analyst to analyze, investigate, and resolve grievances, dental pre-service, and payment appeals. You will collaborate with multiple departments, ensure proper documentation in English, and manage case files to meet regulatory timeliness.

This role emphasizes compliance with CMS and OIC rules and involves coordinating with independent review entities when required. The position requires a Bachelor's or an Associate’s degree with several years in research or auditing