MCS Healthcare Holdings, LLC
Representante de Alcance al Proveedor Regular Non Exempt GENERAL DESCRIPTION: Provides administrative support by coordinating service support and maintaining compliance with established protocols. Receives, responds to, and effectively forwards calls and/or requests received in the unit and follows up for…
Especialista de Comunicaciones Corporativas y Relaciones Públicas Regular Exempt GENERAL DESCRIPTION: Responsible for developing communications plans, participating in planning sessions, evaluating, standardizing, coordinating, and editing the content of the material published for the company’s stakeholders both internally and externally. Identifies…
Especialista de Comunicaciones Corporativas y Relaciones Públicas Regular Exempt GENERAL DESCRIPTION: Responsible for developing communications plans, participating in planning sessions, evaluating, standardizing, coordinating, and editing the content of the material published for the company’s stakeholders both internally and externally. Identifies…
Tecnico(a) de Farmacia/STAR Regular Non Exempt GENERAL DESCRIPTION: Oversees interventions and/or calls to clients (beneficiaries, providers, pharmacies) to promote the correct use of medications and follow the prescription to increase adherence in the identified population, which results in a significant…
Representante de Servicio al Cliente I CC Regular Non Exempt GENERAL DESCRIPTION: Responsible for providing an excellent service when answering requests from policyholders, members, and providers through phone calls received. Solves situations or service needs, channeling them through the established…
Lider de Administracion de la Red 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…
Especialista en Revision de Utilizacion Hospitalaria 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…
Especialista de Manejo de Cuidado US Regular Exempt GENERAL DESCRIPTION: Conducts nursing functions in performing care management processes, organizational determinations, and transitional care, including, health assessments, biopsychosocial needs assessment, and identification of barriers for policyholders with high risk and high…
Representante de Manejo de Prima 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…
Representante de Servicio al Proveedor Regular Non Exempt GENERAL DESCRIPTION The Provider Service Representative is responsible for answering and make telephone calls to participating and non participating providers offering services in the service area and outside the plan service area,…
Administrador(a) de Servidores Regular Exempt GENERAL DESCRIPTION: Responsible for installing, managing, and optimizing enterprise servers and related components to achieve high performance of various business applications, tuning servers as needed. This includes but is not limited to ensuring the availability…
Lider del Centro de Llamadas de Farmacia y Determinaciones de Cubierta Regular Non Exempt GENERAL DESCRIPTION: Responsible for assisting and monitoring operational processes for Pharmacy Technicians in their delegated tasks, such as identifying potential errors or gaps in information during…
Lider en Servicios a Hogares Regular Exempt GENERAL DESCRIPTION: Responsible for monitoring effective strategies and initiatives to ensure proper coordination of daily operations impacting the Long Term Care Home Program. Develops, promotes, and maintains a healthy business relationship with participating…
Representante de Servicio I SC Aguadilla Regular 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…
Supervisor(a) de Calidad en Farmacia Regular Exempt GENERAL DESCRIPTION: Responsible for overseeing the quality assurance, performance monitoring, and training functions of pharmacy utilization management within the unit. Ensures that operational processes meet established standards, regulatory requirements, and organizational goals. Designs…
Supervisor(a) de Determinaciones de Farmacia Regular Exempt GENERAL DESCRIPTION: Responsible for the management of the Pharmacy utilization management drugs unit for all the company's business lines. ensure that the evaluations of clinical pre authorizations conducted by their team are based…
Socio(a) de Negocios de Recursos Humanos Regular Exempt GENERAL DESCRIPTION: Responsible for overseeing employee relations within a designated group of Departments/Units at MCS. The HRBP collaborates with leadership to ensure that Human Resources strategies align with the organization's business objectives…
Analista de Reclamaciones II Regular Non Exempt GENERAL DESCRIPTION: Analyzes claims and/or adjustments in 1500, UB04 format and member reimbursements by applying payment rules for payment adjudication and denial and /or requests for additional information, such as original claims, adjustments,…
Analista del Programa de Valor al Afiliado Regular Non Exempt GENERAL DESCRIPTION: Responsible for handling, validating, and completing requests and reconciliations related to the Beneficiary Value Program. Assess program reconciliation and collaboration with cross functional teams to enhance overall program…
Director(a) de Seguridad de Infraestructura de IT Regular Exempt GENERAL DESCRIPTION: Responsible for overseeing the operational activities related to the Information Technology security infrastructure. Provides strategic direction for the organization's technical infrastructure and security, including hardware, software, servers, databases, storage…
Tecnico(a) de Servicio Clinico Regular Non Exempt GENERAL DESCRIPTION: Responsible for receiving, registering, and forwarding requests for organizational determination and/or any associated clinical documentation or documentation for the clinical management of the insured. Works with the authorizations of services already…
Asistente Administrativa Regular Non Exempt GENERAL DESCRIPTION: Responsible for assisting and providing administrative support in managing the operational processes of their unit or department following MCS guidelines, policies, and procedures. ESSENTIAL FUNCTIONS: Makes, refers, and answers department phone calls. Attending…
Supervisor(a) de Gobernanza de Datos Regular Exempt GENERAL DESCRIPTION: Responsible for supervising the design, implementation, and continuous improvement of MCS’s enterprise data governance framework. Provides oversight for the execution of governance policies, standards, and initiatives, ensuring alignment with organizational strategy…
Analista de Gobernanza de Datos Regular Exempt GENERAL DESCRIPTION: Supports the execution and continuous improvement of data governance matters by configuring, maintaining, and enhancing the tools, technologies, and processes required to manage data effectively. Facilitates technical enablement of data governance…
Especialista en Revision de Utilizacion Hospitalaria 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…
Especialista de Utilizacion Medica Regular Exempt GENERAL DESCRIPTION: The Medical Utilization Specialist works with patients with high medication utilization, specialty physicians, PCP visits, hospital and emergency room admissions, readmissions, etc., to develop an individualized care plan aimed at improving utilization.…
Analista de Elegibilidad & Afiliacion Classicare Temporero Temporary Replacement Non Exempt GENERAL DESCRIPTION: Responsible for analyzing and assessing prospects’ eligibility for the Medicare Advantage Programs administered by the company. This assessment will be based on the eligibility rules and policies…
Especialista de Manejo de Cuidado 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…
Especialista de Administracion de la Red Regular Exempt GENERAL DESCRIPTION: Execute provider interventions to discuss performance metrics, monitor progress, and coordinate strategic events and interactions among physicians. Analyze the market data and adequacy, follow the legal requirements by type of…
Especialista de Credencializacion Regular Exempt GENERAL DESCRIPTION: Responsible for evaluating and managing the credentialing and recredentialing processes for healthcare professionals and facilities participating in the provider network across all lines of business. Ensures compliance with regulatory requirements, accreditation standards, and…
Lider de IPA Regular Exempt GENERAL DESCRIPTION: Provides strategic leadership between Independent Practice Associations (IPAs) and the organization, driving alignment on performance goals, regulatory compliance, and operational efficiency. This role provides expert guidance, in depth analytics, and actionable insights to…
Analista de Reclamaciones III Regular Non Exempt GENERAL DESCRIPTION: Analyzes, processes, and adjudicates all types of complex claims both in CMS1500 and UB 04 formats using the highest degree of analysis for payment and/or decline in, for example, adjustments, reimbursements…
Analista de Eficiencia del Programa de Valor al Afiliado 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 received and managed in the…
Especialista de Administracion de la Red Regular Exempt GENERAL DESCRIPTION: Execute provider interventions to discuss performance metrics, monitor progress, and coordinate strategic events and interactions among physicians. Analyze the market data and adequacy, follow the legal requirements by type of…
Analista de Reclamaciones II Regular Non Exempt GENERAL DESCRIPTION: Analyzes claims and/or adjustments in 1500, UB04 format and member reimbursements by applying payment rules for payment adjudication and denial and /or requests for additional information, such as original claims, adjustments,…
Analista de Reclamaciones III Regular Non Exempt GENERAL DESCRIPTION: Analyzes, processes, and adjudicates all types of complex claims both in CMS1500 and UB 04 formats using the highest degree of analysis for payment and/or decline in, for example, adjustments, reimbursements…
Especialista de Analisis y Monitoreo de la Red Regular Exempt GENERAL DESCRIPTION: Responsible for preparing and analyzing reports that support negotiation and contracting strategies with providers, including facilities, hospitals, ancillary services, and professional services. This position contributes to projects focused…
Comprador(A) GENERAL DESCRIPTION: The Buyer is responsible for executing the company's purchasing process to obtain the best services, products, and suppliers based on company needs. Receives and processes the purchase requisitions received in the unit. Responsible for overseeing the assigned…
Promotor(A) de Ventas Carolina GENERAL DESCRIPTION Promotes MCS Classicare products and services by participating in events and/or formal and informal activities approved by the Medicare Center and Medicaid Services (CMS). Ensures compliance with the requirements established by the regulatory agency.…