Opportunité d’Emploi à Porto Rico : Especialista De Querellas Y Apelaciones
Type de Poste : Especialista De Querellas Y Apelaciones
Entreprise : Mcs Healthcare Holdings, Llc
Description du Poste :
L’Especialista de Querellas y Apelaciones joue un rôle crucial dans le traitement des plaintes et des appels formulés par les membres, les assurés et les fournisseurs, en conformité avec les réglementations contractuelles et les droits des patients.
Responsabilités Essentielles
- Analyse et Résolution : Évalue et répond aux réclamations des assurés de MCS Classicare ou MCS Life, conformément aux régulations de CMS et aux politiques internes.
- Collaboration : Travaille avec d’autres départements pour analyser et résoudre les enjeux soulevés dans les plaintes.
- Documentation : Enregistre toutes les investigations liées aux plaintes dans la plateforme de gestion appropriée, garantissant ainsi la traçabilité et la conformité.
- Suivi des Métriques : Surveillance constante des délais de gestion des plaintes pour préserver les indicateurs de performance clés.
- Rapport : Fournir des données à la direction pour les rapports réglementaires dans les délais impartis.
- Formation : Assure la formation des nouveaux employés sur les politiques de gestion des plaintes et leurs implications.
- Participation : Engage dans les réunions opérationnelles et les projets d’implémentation relatifs aux processus de gestion des plaintes.
Qualifications Requises
Éducation :
- Baccalauréat en Administration des Affaires, Finance, Sciences Sociales ou Justice Criminelle, avec un minimum de trois ans d’expérience pertinente.
- Ou un Diplôme Associé et cinq ans d’expérience dans un rôle similaire.
Compétences Linguistiques : Capacité intermédiaire en espagnol et en anglais, tant à l’écrit qu’à l’oral.
Conditions de Travail
Salaire : À déterminer.
Localisation : Porto Rico
Date de Publication : 16 juillet 2025
MCS Healthcare Holdings, Llc est un employeur qui prône l’égalité des chances et applique des actions affirmatives pour attirer des femmes, des minorités, des anciens combattants protégés et des personnes en situation de handicap.
Réflexions Critiques
Ce poste demande à la fois une rigueur professionnelle et une connaissance approfondie des réglementations en matière de santé, ce qui souligne l’importance d’une préparation adéquate pour tous les candidats. Il est essentiel que les postulants comprennent non seulement les exigences du poste, mais aussi l’environnement dynamique dans lequel ils vont évoluer. Cela inclut la nécessité de respecter des délais stricts pour la résolution des plaintes et de maintenir une communication claire auprès des assurés.
En revenant sur l’importance de la diversité et de l’inclusion dans le processus de recrutement, cette annonce se conforme aux standards éthiques recommandés, assurant ainsi une représentation équitable au sein de l’organisation.
📅 Date de publication de l’offre : Wed, 16 Jul 2025 22:01:04 GMT
🏢 Entreprise : Mcs Healthcare Holdings, Llc
📍 Lieu : Puerto Rico
💼 Intitulé du poste : Especialista De Querellas Y Apelaciones
💶 Rémunération proposée :
📝 Description du poste : Especialista de Querellas y ApelacionesGENERAL DESCRIPTION:Analyzes, investigates, resolves, and answers grievances and/or appeals filed by members, insureds, and Providers within the time stipulated contractually for both Lines of Business (LOB) and following the terms stated in the contracts established in MCS and the rights of Patients and Providers.ESSENTIAL FUNCTIONS:
- Analyzes, investigates, resolves, and answers grievances and/or appeals filed by MCS Classicare or MCS Life policyholders, as assigned and in compliance with CMS regulation, Office of the Commissioner of Insurance (OCI), MCS and Grievances and Appeals Unit Policies & Procedures, others.
- Consults other MCS Departments or Units, as part of the analysis and investigation process, and Delegated Entities and/or suppliers.
- Validates responses from other Departments and/or Units, assessed the possible root cause, identifies areas of opportunity, and requires collaboration and documentation according to the impacted issue.
- Documents the grievances and/or appeals investigations in the Grievances & Appeals management platform to complete the resolution or determination of the case.
- For appeals, in the event a reconsideration or member request is denied, for MCS Classicare LOB, submits cases to CMS contracted Independent Review Entities (IRE – Maximus). Case files must be documented in english under the appeals process, considering required documentation and timeliness. This process impacts directly, two Stars metrics related to timeliness and upheld by IRE.
- For appeals, in the event a reconsideration or member request is denied and request second level appeal, for MCS Life LOB, complies with the Office of the Commissioner of Insurance (OCI) regulation and submits cases to Independent Review Organizations (IRO). Case files must be documented in english under the appeals process, considering required documentation and timeliness.
- For Grievances, records, manages, and resolves member’s issue.
? Complies with verbal contact with the insured and/or authorized representative, or provider during the case investigation process to document and categorize the issue presented.? Reviews documentation provided by operational areas to ensure proper resolution.? Resolves grievances according to the timeliness established by regulation (24 hours if expedite or 30 calendar days for standard). Also consider Office of Patient Advocate (OPP) grievances management’ timeframes.? Investigation process includes verbal notices, written notices, RCA, if applicable, within others for proper compliance with process.
- Constant monitoring of grievances and appeals timely management and procedure to avoid impact on 3 Stars metrics related to CTM, Appeals Timeliness and Appeals Upheld.
- Complies with the delivery of data required by immediate supervisor to complete reports required by Regulatory Agencies, in the established timeframes and as requested (Example: CMS, ASES, OPP, OCI, other Departments, and/or MCS Units).
- Identifies providers and insureds with recurring grievances and informs immediate supervisor for referral and intervention by the appropriate department(s), e.g., Provider Department, Compliance Department, others.
- Provides training on Grievances and Appeals Policies and Procedures and their impact on the Organization, in the New Employee Orientation or as requires by the management team.
- Collaborates, as required, in the review of Policies and participates in the definition of grievances and/or appeals processes with the Manager, Supervisor and Unit Director.
- If required, participates in MCS Operational meeting or Committees that, due to their function, require personnel with experience in managing Grievances and Appeals. For example, Satisfaction Committee, MOC, others.
- Participates in program review and/or implementation projects, where staff with experience in managing Grievances and Appeals is required, if needed, e.g., update of PMHS, Beacon, others.
- 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 in Business Administration, Finance, Social Sciences, or Criminal Justice. Minimum of three (3) years of experience in research, auditing, or client/provider service, preferably within the Health Insurance Industry.OREducation and Experience: Associate’s degree in Business Administration, Finance, Social Sciences, or Criminal Justice or sixty (60) approved university credits. Minimum of five (5) years of experience in research, auditing, or client/provider service, preferably within the Health Insurance Industry.« Proven experience may be replaced by previously established requirements. »Certifications / Licenses: N/AOther: Knowledge in Beacon and HPMS preferred.Languages:
Spanish – Intermediate (writing, conversation, and comprehension)
English – Intermediate (writing, conversation, and comprehension)« Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento »
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