Senior Grievances & Appeals Investigator

MCS Puerto Rico; San Juan (PR); On-site; USD 55,000 - 90,000; Full time

Job summary

MCS Puerto Rico is seeking a detail-oriented reviewer to analyze, investigate, and resolve grievances and pre-service appeals across CMS/CTM, OIC, and AOD processes. The role emphasizes documenting chronology, identifying root causes, and coordinating corrective actions to ensure timely resolution in accordance with Evidence of Coverage.

Ideal candidates have a Bachelor’s degree in a related field and at least four years in research, auditing, or client/provider service within the healthcare

Qualifications

• Bachelor’s Degree in a relevant field with 4+ years of research, auditing, or client/provider service experience in healthcare insurance.
• Experience in regulatory compliance and grievance resolution is preferred.
• Proficiency in both English and Spanish, written and spoken.

Responsibilities

• Record, manage, and resolve cases submitted through CTM and related channels following regulatory requirements.
• Document investigation chronology in CMS/database with appropriate evidence of coverage language.
• Identify root causes and work with management to implement corrective actions to prevent recurrence.
• Participate in CTM workgroups and coordinate with other departments for sustainable actions.
• Ensure timely validation and registration on electronic platforms for pre-service appeals and related processes.

Skills

Spanish Advanced

English Advanced

Education

Bachelor’s Degree in Business Administration, Finance, Social Services, or Criminal Justice

Tools

HPMS

PMHS

Beacon Healthcare System

TruCare

Job description

MCS Puerto Rico is seeking a detail-oriented reviewer to analyze, investigate, and resolve grievances and pre-service appeals across CMS/CTM, OIC, and AOD processes. The role emphasizes documenting chronology, identifying root causes, and coordinating corrective actions to ensure timely resolution in accordance with Evidence of Coverage.

Ideal candidates have a Bachelor’s degree in a related field and at least four years in research, auditing, or client/provider service within the healthcare