Preauthorization Nurse

Triple-S Management Corp.; Puerto Rico; On-site; USD 60,000 - 80,000; Full time

Job summary

Triple-S Management Corp. in Puerto Rico seeks a Registered Nurse to evaluate, coordinate, and monitor service requests for CMS and regulatory compliance.

You will work with providers and policyholders, ensure accurate coding and coverage terms, and document interventions in the electronic system. A PR RN license and 1–3 years clinical experience are preferred.

Qualifications

• Bachelor's Degree in Nursing required.
• Current Puerto Rico RN license without restrictions.
• 1–3 years of clinical nursing experience preferred.

Responsibilities

• Receives and evaluates service requests.
• Coordinates services with providers per protocols.
• Evaluates coverage terms, quotes, codes; documents changes.
• Verifies requested codes align with diagnosis or treatment.
• Refers non-compliant cases to the medical officer.
• Makes clinical decisions per established policies.
• Contacts policyholders and providers when cases are resolved.
• Documents all interventions in the electronic system.
• Follows up on rental equipment cases for buy transition.
• Refers cases to Disease Management/Case Management.
• Handles appeals with medical advisor when needed.
• Performs all other duties as assigned.

Job description

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
• 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.