Healthcare Claims Adjudication Analyst II

MCS Puerto Rico; San Juan (PR); On-site; USD 42,000 - 54,000; Full time

Job summary

MCS Healthcare Holdings, LLC. is seeking a claims adjudication specialist in Puerto Rico with a focus on CMS-1500/UB-04 formats and member reimbursements. The role involves applying payment rules to determine adjudication outcomes, handling COB and grievances, and maintaining regulatory compliance.

Qualifications include a Bachelor’s or equivalent, 1–3+ years in claims processing, and knowledge of CPT-4, ICD-10, and HCPCS. Bilingual Spanish/English skills are preferred.

Qualifications

• Bachelor’s Degree with 1+ year claims processing or provider call center experience.
• Associate’s Degree with 2+ years in claims processing or related role.
• High School Diploma with 3+ years in claims processing or related role.
• Knowledge of CPT-4, ICD-10 and HCPCS coding manuals.
• Spanish (Intermediate) and English (Basic) language skills.

Responsibilities

• Evaluate and apply payment rules to adjudicate claims and adjustments.
• Process all types of original claims, adjustments, grievances, and reimbursements.
• Identify evidence of fraud or misuse during adjudication.
• Refer claims to relevant areas for additional information or approvals.
• Report system or coverage deficiencies to supervisor.
• Notify supervisor of payment errors or declines during adjudication.
• Maintain productivity and deliver reports as required.
• Comply with policies, laws, and industry regulations.

Skills

Spanish (Intermediate)

English (Basic)

Healthcare coding knowledge

CPT-4

ICD-10

HCPCS

Education

Bachelor's Degree

Associate's Degree (60–64 credits)

High School Diploma or Technical Course

Tools

CPT-4

ICD-10

HCPCS

Job description

MCS Healthcare Holdings, LLC. is seeking a claims adjudication specialist in Puerto Rico with a focus on CMS-1500/UB-04 formats and member reimbursements. The role involves applying payment rules to determine adjudication outcomes, handling COB and grievances, and maintaining regulatory compliance.

Qualifications include a Bachelor’s or equivalent, 1–3+ years in claims processing, and knowledge of CPT-4, ICD-10, and HCPCS. Bilingual Spanish/English skills are preferred.