mcs

Regular Non-Exempt GENERAL DESCRIPTION: Analyzes claims and/or adjustments submitted in Centers for Medicare and Medicaid Services Form 1500 (CMS‑1500) and Uniform Billing Form 04 (UB‑04) formats, as well as member reimbursements, by applying payment rules to determine appropriate adjudication, denial, or the need for additional information. This...

Regular Non-Exempt General Description Responsible for managing and performing key tasks within the recruitment process, with a focus on onboarding, contracting, and compliance. This position acts as a bridge between the Talent Acquisition team and new employees, ensuring an efficient and positive experience. The role includes administrative...

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 the...

Regular Exempt GENERAL DESCRIPTION: Responsible for the execution, monitoring, and evaluation of clinical pharmacy initiatives to ensure they align with organizational goals, regulatory requirements, and performance standards. Supports the development of cost-effective, patient-centered interventions, analyzes clinical and operational data, and...

Regular Non-Exempt GENERAL DESCRIPTION: Responsible for the monitoring and implementation of regulatory processes such as Explanation of Benefits (EOB), Maximum Out of Pocket (MOOP), and Financial Information Report (FIR) transactions. Monitor monthly invoices, validate, and create Likely to Benefit (LTB) letters for the Medicare Prescription Payment Plan...

Regular Exempt GENERAL DESCRIPTION: Assists in investigating cases for resolution in compliance with the applicable regulations, guidelines, and contractual agreements. Participates in the implementation processes of the special networks, prompt payment, and directory complaints, which entails analyzing the operational impact, validations, and...

Regular Exempt GENERAL DESCRIPTION: Responsible for directing, developing initiatives, and establishing plans of action to ensure compliance with service standards, comply with the needs of internal and external clients, and achieve the renewal goals established by the company. Responsible for the service and renewals of the groups under...

Regular Exempt GENERAL DESCRIPTION: Carries out nursing functions in performing care management process, organizational determinations, and transitional care, including, but not limited to, health assessments, biopsychosocial needs assessment, and barriers for policyholders with medical conditions to develop a comprehensive and customized care plan....

Regular Exempt GENERAL DESCRIPTION: Supports regulatory compliance through audit readiness, regulatory reviews, corrective action plan management, and monitoring of provider network activities, including contracting, credentialing, and recredentialing. Responsible for monitoring and analyzing metrics, key performance indicators (KPIs), and operational...

Regular Exempt GENERAL DESCRIPTION: Performs health risk assessments (HRA’s) to determine if the member is eligible for Special Supplemental Benefits for the Chronically Ill (SSBCI). Reviews the member's individualized care plan and performs specific interventions to monitor the member's health status. ESSENTIAL FUNCTIONS: Performs Health Risk...

Regular Exempt GENERAL DESCRIPTION: Represents the company in official service negotiations with assigned group. Attend, channel, and solve the different situations from customers, underwriters, and producers as required. Responsible for coordinating and negotiating with the underwriting department the renewal proposal of groups assigned to their Book of...

Regular Exempt GENERAL DESCRIPTION: The Senior Account Executive represents the company in official service procedures and group renewals. Ensures effective attendance, communication, and resolution of various service-related situations as required by the clients. Serves as primary liaison between the employer or group and the management of the...

Regular Exempt GENERAL DESCRIPTION: Responsible for identifying a business's needs, data, and market trends to design plans that align with the organization's goals. Leads and coordinates effective strategies for health services network management at both local and international levels with a focus on service quality, process improvement, and contractual...

Regular Exempt GENERAL DESCRIPTION: Responsible for driving consistent and impactful brand visibility and merchandising across the company's facilities and partner locations. Ensures and executes trade marketing initiatives, strengthening brand presence, and delivering the tangible expression of the brand within the healthcare insurance industry....

Regular Non-Exempt GENERAL DESCRIPTION: Responsible for managing administrative tasks, coordinating services, and maintaining compliance with established protocols. Serves as a vital link between members, healthcare providers, and the multidisciplinary team within the organization. Facilitates the delivery of services to members in an integrated and...

Regular Non-Exempt GENERAL DESCRIPTION: Responsible for providing high-quality customer service to policyholders, members, and providers through inbound calls. Effectively resolves service inquiries in accordance with established operational processes and service guidelines, while accurately documenting all interactions to ensure service continuity and...

Regular Non-Exempt GENERAL DESCRIPTION: Responsible for coordinating, routing, and following up on operational requests related to the department and/or unit. Provides administrative support, manages documentation, and ensures compliance with internal processes and regulatory requirements, contributing to operational efficiency and service...

Regular Exempt GENERAL DESCRIPTION: Serves as a liaison between the company and extended care home administration to coordinate, refer, and manage documents and/or services related to the company’s Home Health Program. Responsible for handling, channeling, and resolving service situations related to complaints, claims, and operational situations of the...

General Description Guides customers and prospects on the products and services offered by the company. Provides extended guidance to clarify doubts of beneficiaries who present highly complex situations. Solves situations or service needs, channeling them through the established operational processes and service guides. Documents the service provided to...

Regular Exempt GENERAL DESCRIPTION: The Community Outreach Supervisor oversees the daily operations of the Community Outreach team, ensuring effective execution of program activities and compliance with established policies and procedures. This role provides direct supervision to Community Outreach Team Leader and Technicians, supports the implementation...