Provider Service Representative

MCS Puerto Rico; San Juan (PR); On-site; USD 32,000 - 48,000; Full time

Job summary

MCS Healthcare Holdings, LLC in Puerto Rico seeks a Customer Service Representative to answer and make provider and member inquiries, ensuring issues are resolved at the first point of contact and escalating when needed.

Responsibilities include documenting complex benefit inquiries, supporting multiple provider types, maintaining HIPAA compliance, and educating providers on platform tools, with rotating shifts including weekends and holidays.

Qualifications

• Educational options per ad: Bachelor's degree; or 60 credits with 1+ year CS in health insurance; or high school diploma with 2+ years CS.
• Familiarity with medical billing is preferred.
• Availability to work rotating shifts, including Saturdays, Sundays, and holidays.

Responsibilities

• Documents, investigates, and facilitates resolution of complex inquiries related to benefits interpretation, provider configurations, claim edits, eligibility determinations, and COB.
• Serves as the primary point of contact for provider-related service inquiries and issues for participating and non-participating providers.
• Maintains HIPAA and data privacy compliance in all customer interactions and system usage.
• Educates providers and staff on provider platform tools, including system access, account creation, access recovery, and functionalities.
• Provides feedback and participates in continuous improvement initiatives to enhance service quality.
• Adheres to call center processes, KPIs, and scripts to ensure consistent service delivery.

Skills

Customer Service

Telephone Etiquette

Keyboarding

Spanish (Intermediate)

English (Intermediate)

Education

Bachelor's Degree

60 college credits

High School Diploma

Job description

GENERAL DESCRIPTION:

Responsible for answering and making telephone calls to participating and non-participating providers offering services in the service area and outside the plan service area, as well as to policyholders. Guarantees that situations or service needs are solved at the time of the call and, if necessary, refer to their supervisor any situation that cannot be solved according to established operational processes and service guidelines.

Regular

Non-Exempt

GENERAL DESCRIPTION:

Responsible for answering and making telephone calls to participating and non-participating providers offering services in the service area and outside the plan service area, as well as to policyholders. Guarantees that situations or service needs are solved at the time of the call and, if necessary, refer to their supervisor any situation that cannot be solved according to established operational processes and service guidelines.

ESSENTIAL FUNCTIONS:

• Accurately documents, investigates, and facilitates resolution of complex inquiries related to benefits interpretation, provider configurations, claim edits, eligibility determinations, and Coordination of Benefits (COB), coordinating with internal departments as needed to ensure timely, accurate, and compliant resolution for members and policyholders.


• Serves as the primary point of contact for provider-related service inquiries and issues, supporting Primary Care Physicians, Specialists, Subspecialists, Dentists, Allied Health Providers, Laboratories, and Hospitals, both participating and non-participating, within the MCS Classicare and MCS Life Networks.


• Ensures confidentiality, security, and proper handling of sensitive information by maintaining full compliance with the Health Insurance Portability and Accountability Act (HIPAA), data privacy policies, and all applicable regulatory and company guidelines throughout all customer interactions and system usage.


• Educates providers and their staff on effective use of provider platform tools, including system access, account creation, access recovery, account unlocking, and available functionalities, ensuring efficient and seamless provider engagement.


• Provides feedback and participates in continuous improvement initiatives by identifying service gaps, recurring issues, or process inefficiencies observed during customer interactions, contributing to enhancements in service quality and operational performance.


• Participates in additional departmental or company initiatives to support operational efficiency, productivity improvements, and service quality enhancement, in alignment with established call center processes and performance objectives.


• Handles inbound calls following established protocols, delivering quality service with a focus on first call resolution, accurately evaluating, resolving, documenting, or escalating customer inquiries according to policies and procedures.


• Meets established key performance indicators (KPIs), including productivity, schedule adherence, call handling metrics, quality standards, documentation accuracy, and professional customer interactions, in compliance with approved protocols.


• Adheres to established operational policies, procedures, scripts, and service guidelines to ensure consistent, standardized, and compliant service delivery.


• Utilizes the telephone system according to assigned schedules and operational guidelines to support call center efficiency and performance metrics.


• 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: Bachelor’s Degree from an accredited institution. At least six (6) months of experience performing duties in a similar position in Customer Service areas, preferably in a Call Center in the Health Insurance Industry.

OR

Education and Experience: Sixty (60) college credits, equivalent to two (2) years of study or an associate degree. At least one (1) year of experience working in Customer Service areas, preferably in a Call Center in the Health Insurance Industry.

OR

Education and Experience: High School Diploma. At least two (2) years of experience working in Customer Service areas, preferably in a Call Center in the Health Insurance Industry.

“Proven experience may be replaced by previously established requirements.”

Certifications / Licenses: Not required.

Other: Knowledge of medical billing, preferably. Availability to work rotating shifts, Saturdays, Sundays, and holidays, per the operation’s requirements. Customer Service oriented, keyboard and telephone etiquette knowledge.

Languages:

Spanish – Intermediate (comprehensive, writing and verbal)

English – Intermediate (comprehensive, writing and verbal)

MCS Healthcare Holdings, LLC. (MCS) is an Equal Employment Opportunity Employer and take affirmative action to recruit Protected Veterans and Individuals with Disabilities. MCS is a participating E-Verify employer.