Especialista de Querellas de Pago Puntual

Especialista de Querellas de Pago Puntual

Regular

Exempt

GENERAL DESCRIPTION:

Analyzes, investigates, resolves, and answers complaints filed by providers related to the Prompt Payment Act for Classicare

and Commercial lines of business. Manages payment disputes for providers not participating in the Classicare network and

answers complaints within the time stipulated in the applicable regulation or contract as applicable for the different lines of

business.

ESSENTIAL FUNCTIONS:

• Analyzes, investigates, resolves, and answers complaints filed by participating providers related to the Prompt Payment Act for the Commercial and Classicare lines of business.
  
• Analyzes, investigates, resolves, and responds to grievances filed by non-participating providers based on the administrative procedure for the resolution of Prompt Payment Grievances and Open Negotiation notice.
  
• Gathers all necessary documents with the required information from the investigation to make a final determination of the case in the Grievance System and the case file.
  
• Identifies situations with providers that affect other departments and monitors areas of opportunity based on the impact of the investigations, and coordinates special meetings for case resolution.
  
• Complies with submitting reports required by regulatory agencies promptly and as requested (OCS, ASES, OPP, CMS, other MCS departments/units).
  
• Identifies providers with recurring complaints and refers them to the Compliance and Physician Network Department for intervention or another department/unit as requested.
  
• Provides training on Timely Payment Grievance Policies and Procedures and handling of payment disputes and their impact on the company, in coordination with the Organizational Development Unit.
  

Assists the Legal Department in investigations of appeals received by the Office of the Commissioner of Insurance (OCS) as requested. If required, realize visits with medical groups, primary care physicians and other providers to investigate and/or

verify information as appropriate.

• Participates in different committees that are required by regulatory agencies or that, due to their function, require personnel with experience in grievances and/or appeals, such as the Prompt Payment Grievance Committee, among others.
  
• Submit cases to Centers for Medicare and Medicaid Services (CMS) contracted entities (First Coast, Maximus), submit cases and document them in English following the standards established in the regulation.
  
• 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 or Criminal Justice. Minimum of three (3) years of previous related experience in the areas of investigation, auditing, customer/provider service, Prompt Payment process, claims handling, and or billing, preferably in the healthcare industry. Knowledge of prompt pay law required.

"Proven experience may be replaced by previously established requirements"

Certifications / Licenses: Valid driver's license in the Commonwealth of Puerto Rico.

Other: N/A

Languages:

Spanish Advanced (comprehensive, writing and verbal)

English Advanced (comprehensive, writing and verbal)

“Somos un patrono con igualdad de oportunidad en el empleo y tomamos Accià³n Afirmativa para reclutar a Mujeres, Minorà­as, Veteranos Protegidos y Personas con Impedimentoâ€