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Regular Exempt **GENERAL DESCRIPTION:** Analyzes, investigates, supports, and answers Grievances, Dental Pre-Service, and Payment Appeals filed by members, insureds, Providers, and/or Non-Part Providers within the time stipulated contractually for both Lines of Business (LOB)and following the terms stated in the contracts established and the...

At Fluor, we are proud to design and build projects and careers. We are committed to fostering a welcoming and collaborative work environment that encourages big-picture thinking, brings out the best in our employees, and helps us develop innovative solutions that contribute to building a better world together. If this sounds like a culture you would like to...

Regular Exempt **GENERAL DESCRIPTION:** The Coding & Payment Rule Specialist is responsible for identifying coding guidelines established by the American Medical Association's (AMA) standard classification systems (ICD-10, CPT, HCPCS) and payment rules established by the Centers for Medicare & Medicaid Services (CMS) for the proper and timely...

Regular Exempt **GENERAL DESCRIPTION:** Manages and ensures the effective execution of the Care Management Program work plan for the Company's lines of business. Ensures that the appropriate resources are in place to ensure compliance with the appropriate care management of the participating members of the program(s). Participates in designing,...

Regular Non-Exempt **GENERAL DESCRIPTION:** Calls medical offices to request, receive by fax, and register documents contained in the medical records of Classicare policyholders, as required and according to the different initiatives worked on in the unit. Refers documents received by the medical offices to the Risk Assessment unit, to complete...

Esta Convocatoria es parte del Nuevo Proceso de Adquisición de Talento en el Servicio de Carrera de las Entidades Participantes del Gobierno de Puerto Rico **Comisión de Juegos del Gobierno de Puerto Rico** **159 Calle Chardón, Piso 2, San Juan, Puerto Rico, 00918** Patrono con igualdad de oportunidades de empleo CONVOCATORIA A EXAMEN Convocatoria...

**Job Summary** Strategic and operational leader responsible for designing, implementing, and optimizing the clinical excellence shared services unit within Clinical Operations. This role ensures that cross-functional clinical and administrative processes are agile, scalable, data-driven, and aligned with the highest quality standards. The Director will lead...

Regular Non-Exempt **GENERAL DESCRIPTION:** Supports daily unit operations by completing document intake, evaluation, classification, and distribution processes. Provides guidance to technicians, resolves escalated issues, and acts as a liaison between internal and external teams to ensure efficient workflow and service delivery. Monitors...

Temporary - AEP Non-Exempt **GENERAL DESCRIPTION:** The Customer Service Representative I – SC is responsible for assisting customers and prospects with information about the company's products and services. They address and clarify any questions from beneficiaries who have concerns. Resolves service needs by following established operational...

Regular Exempt **GENERAL DESCRIPTION:** Conducts prospective reviews (preauthorization’s) of items or services provided to beneficiaries using the Clinical Guidelines criteria for assessing medical necessity. Determines the appropriate level of care according to the severity of the subscriber’s condition. Ensures the appropriate use of...

Regular Exempt **GENERAL DESCRIPTION:** Evaluates utilization in clinical records and hospital facilities concurrently and retrospectively. Identifies and refers to other clinical departments (Case management, condition management, among others) cases for the management of treatment alternatives. Makes efforts to receive advice in difficult...

Regular Exempt **GENERAL DESCRIPTION:** Provides education to internal and external clients on operational topics that promote efficiency in the process executed by our providers and business partners, such as the Risk Adjustment payment model “CMS-HCC”, ensuring best practices in coding standards and clinical documentation within the medical...

Regular Exempt **GENERAL DESCRIPTION:** Responsible for the ongoing monitoring of all elements of the Special Needs Plan Care Coordination (SNP-CC) as needed to comply with regulatory requirements and quality indicators. Evaluates care coordination frameworks, identifies risks and improvement opportunities, supports audit readiness, and works...

Temporary - AEP Non-Exempt **GENERAL DESCRIPTION:** The Customer Service Representative I – SC is responsible for assisting customers and prospects with information about the company's products and services. They address and clarify any questions from beneficiaries who have concerns. Resolves service needs by following established operational...

Regular Non-Exempt **GENERAL DESCRIPTION:** The Beneficiary Value Program Efficiency Clerk is responsible for the accurate classification, registration, and monitoring of operational items related to Te Paga within designated electronic portals. The Clerk ensures items are properly categorized, validated, documented, and escalated when issues...

Regular Non-Exempt **GENERAL DESCRIPTION:** Analyzes, processes, and adjudicates all types of complex claims submitted in Centers for Medicare and Medicaid Services Form 1500 (CMS‑1500) and Uniform Billing Form 04 (UB‑04) formats, applying the highest level of analytical judgment to determine appropriate payment or denial. This includes the...

Regular Non-Exempt **GENERAL DESCRIPTION** : The Beneficiary Value Program Efficiency Analyst is responsible for preserving the quality of the product by analyzing and developing operational data and report requests related to Te Paga. Provides administrative and analytical support in the implementation and monitoring of Te Paga-related...

Regular Exempt **GENERAL DESCRIPTION:** Supports the planning, development, and execution of specialty pharmacy programs for both MCS lines of business. Responsible for monitoring and reporting to ensure established programs deliver the expected clinical and financial results. Ensures that specialty medication strategies achieve company goals and...

Regular Non-Exempt **GENERAL DESCRIPTION:** Responsible for receiving, registering, and forwarding applications received within the unit to certify the chronic conditions of beneficiaries for a chronic product. Responsible for the confirmation of chronic conditions for the C-SNP plan members. Enters data from health status and risk factor...

Regular Exempt **GENERAL DESCRIPTION:** The Events and Promotions Executive is responsible for handling and coordinating the logistics of Classicare events and activities and the efforts and initiatives related to the Advantage line of business. Identifies and develops work plans for region-level initiatives and provides recommendations to...