Preauthorization Nurse

Triple-S; Guaynabo (PR); Presencial; USD 65.000 - 90.000; Jornada completa

Descripción de la vacante

Triple-S Salud Inc. is seeking a qualified Registered Nurse to evaluate, identify, and monitor service requests in compliance with CMS, ASES, OPM and Triple-S policies. The role requires careful clinical judgment and coordination with providers.

The ideal candidate holds a Bachelor's Degree in Nursing with an active Puerto Rico RN license and 1–3 years of clinical experience. Puerto Rico licensing must be current and unrestricted.

Formación

• Bachelor’s Degree in Nursing with an active Puerto Rico RN license.
• 1–3 years of clinical nursing experience preferred.
• Current/Active Puerto Rico RN license without restrictions.

Responsabilidades

• Receives and evaluates service requests.
• Coordinates services with providers following established protocols.
• Evaluates terms of coverage, quotes, codes, and changes of level; negotiates rates and documents non-incurred expenses.
• Verifies if requested codes are correct according to the diagnostic or treatment required.
• Refers requests that do not meet clinical criteria to the medical officer.
• M akes clinical decisions in accordance with policies, criteria, guidelines or protocols.
• Contacts policyholders and providers to notify them when a case has been resolved.
• Documents all interventions related to a service request in the electronic application.
• Follows up on policyholders with rental equipment to determine when it’s time to pass from rent to buy.
• Refers cases to Disease Management and Case Management.
• Handles appeals, referring them to the medical advisor if necessary.
• Performs all other duties as assigned.

Conocimientos

Manages Ambiguity

Instills Trust

Collaborates

Customer Delight (Employee)

Action Oriented

Educación

Bachelor's Degree in Nursing

Descripción del empleo

At Triple-S, we are committed to providing meaningful job experiences for Valuable People (Gente Valiosa). We strive for excellence in everything we do, from the way we work together to the way we serve our customers.

When you join Triple-S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses.

Job Summary

Responsible for evaluating, identifying, and monitoring service requests, making sure that they meet the criteria and deadlines established by CMS, ASES, OPM, among other regulatory agencies and that they follow the protocols and policies of Triple-S Salud Inc.

Essential Functions

• Receives and evaluates service requests.
• Coordinates services with providers and verifies that the service is offered following established protocols.
• Evaluates terms of coverage, quotes, codes, and changes of level. Negotiates rates and documents non-incurred expenses.
• Verifies if requested codes are correct, according to the diagnostic or treatment required.
• Refers requests that do not comply with clinical criteria to the medical officer.
• Makes clinical decisions in accordance with established policies, criteria, guidelines or protocols.
• Contacts policyholders and providers to notify them when a case has been resolved.
• Documents all interventions related to a service request in the electronic application.
• Follows up on policyholders with rental equipment to determine when it’s time to pass from rent to buy.
• Refers cases to Disease Management and Case Management.
• Handles appeals, referring them to the medical advisor if necessary.
• Performs all other duties as assigned.

EDUCATION

• Bachelor's Degree in Nursing

Experience

• Bachelor’s Degree in Nursing with valid nursing license. Minimum of one (1) to three (3) years clinical experience, preferably.
• Current/ active license in Puerto Rico Register Nurse without restrictions Member of College of Nursing Professional of Puerto Rico.

LICENSES AND CERTIFICATIONS

• Current / Active Registered Nurse License without restrictions in Puerto Rico (required)

COMPETENCIES

• Manages Ambiguity
• Instills Trust
• Collaborates
• Customer Delight (Employee)
• Action Oriented

It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, sex, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company.

Equality Employment Opportunity/Affirmative Action for People with Disabilities/Veterans. Employer with E-Verify to verify the eligibility of employment of all the new employees.

We encourage Veterans and Disabled to Apply.