Job Description

Utilization Reviewer

Ponce, PR

ABOUT US

At Triple S, we are committed to provide meaningful job experiences for Valuable People (Gente Valiosa). We encourage an environment of very high ethical standards, always excelling in service,

collaboration among the company

, agility

to deliver timely, and embracing accountability for results.

When you join Triple S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses.

Let's build healthier communities together, join now!

ABOUT THE ROLE

Responsible for performing clinical inpatient reviews to assess medical necessity, appropriateness of care, and compliance with regulatory and payer guidelines. This role ensures that patients receive high-quality, cost-effective care while optimizing resources utilization. The Utilization Reviewer collaborates with physicians, case managers, and the hospital discharge planning unit to ensure our members receive the most appropriate level of care in the right setting.

WHAT YOU'LL DO

Conducts ongoing reviews of inpatient hospitalizations to ensure medical necessity and appropriate level of care. Applies evidence-based criteria (e.g., InterQual) to assess treatment plans and documents the clinical review of each audit in the clinical platform, meeting established quality standards. Communicates with physicians and healthcare teams regarding documentation improvements and level-of-care determinations. Identifies potential discharge planning needs early in the hospitalization process; work with social workers or hospital discharge planning team, as necessary. Reviews medical records post-discharge to determine if the hospitalization met our clinical criteria. Identifies cases of inappropriate admission, length of stay, or lack of medical necessity. Discusses adverse determination with the Utilization Review Manager/Supervisor, Medical Advisor, Hospital Coordinator or Treating Physician. Collaborates with appeals teams to support denial management and claim reconsiderations Provides feedback to clinical teams on documentation improvements to prevent future denials. Stays current on utilization review regulations, payer policies, CMS and clinical guidelines. Assists in developing and implementing process improvements in utilization management. Participates in staff education regarding documentation and medical necessity requirements. Participates in the weekend scheduling program. Other duties as assigned by management and as essential.

WHAT YOU'LL BRING

Bachelor's Degree (BD) in Nursing Sciences with one (1) to three (3) years of clinical experience, preferable in hospital environment. Current / Active License in Nursing without restrictions in Puerto Rico. Member of College of Nursing Professionals of PR.

CLOSING DATE: 9/23/2025

It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, sex, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company.


Equality Employment Opportunity/Affirmative Action for People with Disabilities/Veterans". Employer with E-Verify to verify the eligibility of employment of all the new employees.


We encourage Veterans and Disabled to Apply