Providers Operations Management Specialist

MCS Puerto Rico; San Juan (PR); On-site; USD 50,000 - 70,000; Full time

Job summary

MCS Puerto Rico is seeking a professional to assist in investigating cases for resolution in compliance with applicable regulations and contractual agreements. The role involves supporting the implementation of special networks, prompt payment, and directory complaints, analyzing operational impact and developing action plans to ensure compliant processes.

The position requires collaboration across units, preparation of reports, and effective communication with stakeholders.

Qualifications

• Bachelor's degree in Business Administration; at least two years of experience in data management, report development and analysis.

Responsibilities

• Provides support within the unit regarding timely resolutions of grievances and appeals.
• Participates in design and development of success indicators, operational metrics, and process flow analysis.
• Conducts quality calls and reports findings to management to improve service and resolve complaints.
• Develops progress reports, analyzes data, and follows up on actions.
• Creates files of monitoring efforts and submits them to the appropriate units.

Skills

Data analysis

Reporting

Education

Bachelor's degree in Business Administration

Tools

Excel

Job description

GENERAL DESCRIPTION

Assists in investigating cases for resolution in compliance with the applicable regulations, guidelines, and contractual agreements. Participates in the implementation processes of the special networks, prompt payment, and directory complaints, which entails analyzing the operational impact, validations, and implementation of actions to maintain compliance with the directories in all their formats. Responsible for assessing, developing, and establishing an action plan for the identified points in any of these areas to ensure corporate processes.

GENERAL DESCRIPTION

Assists in investigating cases for resolution in compliance with the applicable regulations, guidelines, and contractual agreements. Participates in the implementation processes of the special networks, prompt payment, and directory complaints, which entails analyzing the operational impact, validations, and implementation of actions to maintain compliance with the directories in all their formats. Responsible for assessing, developing, and establishing an action plan for the identified points in any of these areas to ensure corporate processes.

Regular
Exempt

ESSENTIAL FUNCTIONS

• Provides support within the unit regarding timely resolutions of grievances and appeals filed by Addiuva according to the corresponding line of business.
• Participates in the design and development of success indicators, operational metrics, and process flow analysis of the initiatives in their charge.
• Conducts quality calls for Service, Credentialing, and Contracting units and reports findings to management for appropriate action. Develops reports on quality calls made to Service, Credentialing, and Contracting units to obtain metrics that lead to service satisfaction and complaint-handling evaluation.
• Develops progress reports, analyzes data, and provides follow-up for the appropriate actions.
• Creates files of the various monitoring efforts and submits them to the appropriate units as required.
• Receives, analyzes, and seeks solutions to service issues from members and contracted providers, as applicable.
• Refers, directs, and monitors configuration requests from providers, as applicable. This includes documentation in automated systems and/or other designated systems.
• Maintains effective communication with the operational owners of each area, providers, and business partners on issues related to contractual agreements with the company.
• Supports management in meetings with the company operational owners, providers, and business partners and ensure documentation of the agreements to obtain solutions and to provide continuity to what has been established.
• 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, preferably in Business Administration. At least two (2) years of experience in data management, development and production of reports, and analysis.

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

Certifications / Licenses:

N/A

Other:

Knowledge in Excel Intermediate and/or Advanced (vlookup, handling multiple reports and basic formulas). Knowledge of policies, procedures, regulations, and laws applicable to the Insurance Industry.

Languages:

Spanish – Intermediate (comprehensive, writing and verbal)

English – Intermediate (comprehensive, writing and verbal)

“We are an Equal Employment Opportunity Employer and take Aff… ”