Grievances & Appeals Technician

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

GENERAL DESCRIPTION:
Receive the Grievances, Pre-Service Appeals, Post-Service Appeals, Payment Disputes, Payment Appeals, and Administrative Organizational Determinations (AOD) filed by Providers and members, as applicable. Responsible for filling and assigning cases to the Specialists in accordance with established time frames.

Regular
Non-Exempt
GENERAL DESCRIPTION:
Receive the Grievances, Pre-Service Appeals, Post-Service Appeals, Payment Disputes, Payment Appeals, and Administrative Organizational Determinations (AOD) filed by Providers and members, as applicable. Responsible for filling and assigning cases to the Specialists in accordance with established time frames.
ESSENTIAL FUNCTIONS:

• Categorizes and registers in the electronic platforms the grievances, pre-service or post-service appeals received through various sources for both Line of Business, MCS Life, and MCS Classicare.
• Registers the grievances received from the Office of the Patient Advocate and the Late Enrolment Penalty (LEP) Reconsiderations in the system.
• Coordinates calls to members, Providers, or company staff (including emails) if required to validate the allegations on grievances and/or appeals, for proper categorization and referral in accordance with Regulation. If the allegation represents more than one issue, proceed to register the grievances separately according to the category, based on the Regulation and Policies & Procedures of the Unit.
• Receives calls from members and/or Providers and refers them according to procedure.
• Responsible for handling calls received through the teletypewriter (TTY), delegated electronic line (telephone line for hearing impaired persons).
• Validates the member's contract in the eligibility system, prints the details of eligibility dates and address, and attaches this information to the file in the system.
• Assigns grievances, pre-service appeals or post service appeals to the Specialists or Senior Specialists.
• If required, provide data for Grievances and Appeals reports in compliance with timeframes and as required by Regulatory Agencies and/or other Departments or Units of the company.
• In conjunction with the Team Leader manages the filter of Grievances, Appeals and AOD’s received in the Unit to safeguard that all cases are properly identified, analyze, registered, as applicable.
• Provides support in the mailing process to members and/or Providers, as needed and to comply with regulatory timeframes.
• Prepares and mails to members or Providers the Acknowledgment Notice, the Request for AOR Form Notice or Withdrawal Notice.
• 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.
• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
  

MINIMUM QUALIFICATIONS:
Education and Experience: 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.
“Proven experience may be replaced by previously established requirements.”
Certifications/Licenses: N/A
Other: Knowledge of PMHS, Front End, Grievance and Appeals, preferable.
Languages:
Spanish – Intermediate (writing, conversation, and comprehension)
English – Intermediate (writing, conversation, and comprehension)
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