Grievances & Appeals Specialist

MCS Puerto Rico; San Juan (PR); On-site; USD 28,000 - 36,000; Full time

Job summary

MCS Puerto Rico in Puerto Rico is seeking a detail‑oriented Records Clerk to manage grievances, pre/post‑service appeals, and payment disputes. You will assign cases to Specialists and ensure timely processing in alignment with regulatory requirements and unit policies.

The role requires handling calls (including via TTY), verifying eligibility, and maintaining accurate documentation. Proficiency in Spanish and English is expected, with non‑exempt status and regular daytime hours.

Qualifications

• Associate's Degree or at least sixty to sixty-four (60-64) approved college credits equivalent to two (2) years of studies.
• Minimum of one (1) year of related experience in auditing, research, and/or customer/provider service.

Responsibilities

• Categorizes and registers grievances, pre-service or post-service appeals in electronic platforms for multiple lines of business.
• Registers grievances from the Office of the Patient Advocate and LEP Reconsiderations in the system.
• Coordinates calls to members, Providers, or staff to validate allegations for proper categorization and referral.
• Receives calls and refers them according to procedure.
• Handles calls received through TTY and other accessibility lines.
• Validates member contracts in the eligibility system and attaches details to files.
• Assigns grievances/appeals to Specialists or Senior Specialists.
• Provides data for Grievances and Appeals reports within regulatory timeframes.

Skills

Auditing

Research

Customer service

Documentation

Telephone etiquette

Education

Associate degree or 60–64 college credits

Job description

MCS Puerto Rico in Puerto Rico is seeking a detail‑oriented Records Clerk to manage grievances, pre/post‑service appeals, and payment disputes. You will assign cases to Specialists and ensure timely processing in alignment with regulatory requirements and unit policies.

The role requires handling calls (including via TTY), verifying eligibility, and maintaining accurate documentation. Proficiency in Spanish and English is expected, with non‑exempt status and regular daytime hours.