Grievances & Appeals Specialist

MCS Health; San Juan (PR); On-site; USD 45,000 - 65,000; Full time

Job summary

MCS Healthcare Holdings, LLC seeks a qualified analyst to analyze, investigate, support, and resolve Grievances, Dental Pre-Service, and Payment Appeals filed by members and providers. The role collaborates with multiple departments, documents cases in the Grievances & Appeals platform, and ensures timely regulatory-compliant resolutions.

Ideal candidates possess a Bachelor’s or equivalent credits with 3+ years in health insurance grievance/audit environments, and fluidity in English and

Qualifications

• Education and experience matching minimum qualifications.
• Knowledge of health insurance industry preferred.
• Be able to analyze and investigate grievances and appeals.

Responsibilities

• Analyze, investigate, resolve and respond to grievances, pre-service, and payment appeals.
• Collaborate with departments, reviewers, and external entities as needed.
• Document cases in the case management platform and communicate updates.
• Ensure timely resolutions according to regulations and timeliness requirements.
• Prepare data and reports for regulatory agencies as requested.

Skills

Spanish (Intermediate)

English (Intermediate)

Education

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

60 approved university credits

Tools

Beacon

PMHS

Job description

MCS Healthcare Holdings, LLC seeks a qualified analyst to analyze, investigate, support, and resolve Grievances, Dental Pre-Service, and Payment Appeals filed by members and providers. The role collaborates with multiple departments, documents cases in the Grievances & Appeals platform, and ensures timely regulatory-compliant resolutions.

Ideal candidates possess a Bachelor’s or equivalent credits with 3+ years in health insurance grievance/audit environments, and fluidity in English and