Senior Claims Analyst: Complex Adjudication & Payments

MCS Puerto Rico; San Juan (PR); On-site; USD 40,000 - 60,000; Full time

Job summary

MCS Puerto Rico in San Juan seeks an experienced claims adjudicator to analyze and process CMS‑1500 and UB‑04 claims, applying the highest level of analytical judgment to determine payments or denials. Responsibilities include handling adjustments, reimbursements, COB, and life insurance claims, with emphasis on accuracy and policy adherence.

The role requires evaluating claims from prior authorization levels, coordinating across departments, and maintaining productivity and compliance with

Qualifications

• Bachelor's Degree with at least 2 years in claims processing or Provider Call Center in Health Insurance.
• Associate's Degree with 3 years of claims processing experience and coding guidelines.
• High School Diploma with 4 years of claims processing experience and coding guidelines.

Responsibilities

• Processes complex claims including adjustments, COB, samplings, US claims, non‑participating provider claims, grievances, reimbursements, and other specialized transactions.
• Evaluates and resolves claims from prior authorization levels and escalates when needed.
• Refers claims to necessary departments to obtain info, support outreach, or secure approvals for payments or denials.
• Reports unusual utilization patterns, suspected fraud, or irregular claim activity to supervisor.
• Reports deficiencies in system configuration or provider agreement discrepancies to ensure integrity.
• Executes the expected volume of claims with accuracy and compliance to policies.
• Maintains productivity reports per departmental guidelines and adheres to all policies and laws.
• May perform other duties as assigned.

Skills

Attention to detail

Bilingual: Spanish/English

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 Puerto Rico in San Juan seeks an experienced claims adjudicator to analyze and process CMS‑1500 and UB‑04 claims, applying the highest level of analytical judgment to determine payments or denials. Responsibilities include handling adjustments, reimbursements, COB, and life insurance claims, with emphasis on accuracy and policy adherence.

The role requires evaluating claims from prior authorization levels, coordinating across departments, and maintaining productivity and compliance with