Qureos Mentor

MCS HEALTHCARE HOLDINGS, LLC

<div>Gerente De Manejo De Utilizacion 
Regular
Exempt 
GENERAL DESCRIPTION:
The Utilization Management Manager is responsible for overseeing the Utilization Management unit, ensuring effective implementation of policies, operational guidelines, and clinical protocols. This role involves leading and developing the team, monitoring performance, and driving compliance with organizational goals. The manager coordinates cross-departmental collaboration, manages work plans, tracks key metrics, and maintains accurate reporting. Additionally, they uphold confidentiality standards and foster strong relationships with internal and external clients to support efficient and compliant utilization management operations.
ESSENTIAL FUNCTIONS:<ul><li>Creates, develops, and updates unit work plans, policies, operational guidelines, and clinical protocols to use in the unit. Develops activities to comply with policies, operational guidelines, and clinical protocols.</li><li>Responsible for ensuring compliance with the goals and objectives established for the Utilization Management unit.</li><li>Collaborates with other departments to achieve goals and objectives set by the Company.</li><li>Responsible for coordinating meetings with staff to keep them updated on the progress of the work plan, achievements, and corresponding metrics.</li><li>Responsible for coordinating and/or providing a development plan for the unit's personnel.</li><li>Responsible for developing unit compliance statistics and metrics.</li><li>Maintains monthly statistics of the activities carried out in the department and ensures that the required reports for each business line are produced promptly, correctly, and completely.</li><li>Maintains effective interaction with both internal and external clients.</li><li>Knows and complies with the confidentiality policy and monitors to ensure compliance.</li><li>Supervises, monitors, trains, evaluates, and corrects personnel among others to comply with his/her role as a supervisor, to assure that his/her personnel fulfill their work plan and comply with their essential functions and that they behave following the policies, standards, norms, and procedures of the Company.</li><li>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.</li><li>May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.</li></ul>
MINIMUM QUALIFICATIONS:
Education and Experience: Bachelor's degree in Nursing Sciences. Five (5) years of experience in a health care environment and supervising staff.
Certifications / Licenses: A valid Nursing and Registration license is required. Other: Knowledge of clinical criteria, ICD-10, and CPT.
Languages:
Spanish &ndash; Advanced (comprehensive, writing and verbal)
English &ndash; Advanced (comprehensive, writing and verbal) 
&ldquo;We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.&rdquo;</div>

Gerente De Manejo De Utilizacion

<div>Evaluador(a) De Perfiles De Salud 
Regular
Non-Exempt 
GENERAL DESCRIPTION:
Responsible for evaluating CHRA (Comprehensive Health Risk Assessment) forms received from Classicare policyholders and coding the documented clinical information according to the guidelines established by the Unit.
ESSENTIAL FUNCTIONS:<ul><li>Performs coding of diagnoses documented in the CHRA (Comprehensive Health Risk Assessment) and registers the data into the appropriate application. Identifies and informs the Supervisor about areas of opportunity to avoid errors that reduce rejected data and may represent a risk to compliance with established coding guidelines.</li><li>Works on post-payment audits of adjudicated claims based on the information contained in the Comprehensive Health Risk Assessment comparing it to the information required, following the operational guidelines established by the unit.</li><li>Generates referrals throughthe electronic app used in the Unit with providers and/or billing representatives, related to CHRA document management, to guide them and/or request correction of medical diagnoses due to incorrect coding, and inadequate, ambiguous, or incomplete medical documentation.</li><li>Process adjustments received for corrections in the CHRA, following the established operational guidance.</li><li>Identifies claims that require the support of the Claims and/or Providers department to be processed.</li><li>Provides weekly, monthly, and quarterly reports to the supervisor on audits performed as required.</li><li>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.</li><li>May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.</li></ul>
Minimum Qualifications:
Education and Experience: Two (2) years of college education equivalent to sixty (60) approved credits from an accredited university or an Associate degree. At least one (1) year of medical billing experience with ICD-9 and ICD-10 coding.
OR
Education and Experience: Associate Degree in Health Information Management Technology from an accredited university. At least six (6) months of experience performing clinical billing and coding processes.
&ldquo;Proven experience may be replaced by previously established requirements.&rdquo;
Certifications / Licenses: A valid Medical Billing Certification and/or ICD-9, ICD-10, and/or other health-related Certifications are preferred.
Other: Knowledge of medical billing processes and ICD-9-CM, ICD-10-CM coding.
Languages:
Spanish &ndash; Intermediate (comprehensive, writing and verbal)
English &ndash; Intermediate (comprehensive, writing and verbal) 
&ldquo;We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.&rdquo;</div>

Evaluador(a) De Perfiles De Salud

<div>Especialista Senior De Querellas Y Apelaciones 
Regular
Exempt 
GENERAL DESCRIPTION: 
Analyzes, investigates, resolves, and answers grievances received through the Center for Medicaid and Medicare Services (CMS) and Complaint Tracking Module (CTM), pre-service appeals, Office of Insurance Commissioner (OIC), and Administrative Organization Determinations (AOD). Ensure timely resolution of cases following contractual obligations and regulatory requirements applicable across all lines of business (LOB) in the company.
<div>ESSENTIAL FUNCTIONS: 
<ul><li>Records, manages, and resolves cases submitted through the CTM. Complies with verbal contact with the insured and/or authorized representative, or provider during the CTM case investigation process to document and categorize the issue presented, and review the documentation provided by operational areas to ensure proper resolution of cases.</li></ul></div><ul><li>Document in English the chronology of investigation and resolution on the CMS database, applying the contractual language of benefits and covered services according to the evidence of coverage, or others.</li><li>Evaluate in the investigation whether a root cause can be identified for the issue. If a root cause is determined, collaborate with the management of the affected operational areas to develop and implement corrective action plans aimed at minimizing the recurrence of CTMs or grievances.</li><li>Actively participate in the CTM workgroup, engaging with leaders from other Departments or Units to review RCA and coordinate on sustainable action plans to prevent future occurrences.</li><li>Complies with the validation and registration on electronic platforms, as applicable for the pre-service appeals processes, such as Clinical, USA, Dental, SSBCI, and Part B medication.</li><li>If a reconsideration or member request for a pre-service appeal is denied by the Classicare LOB, it is responsible for submitting the cases to the CMS contracted Independent Review Entities (IRE - Maximus). If the reconsideration or member request is denied by the MCS Life LOB, and the member requests a second-level appeal, it must follow the compliance guidelines of the OIC regulations and submit the cases to the Independent Review Organizations (IRO). Case files must be documented in English during the appeals process, considering the required records and timeliness.</li><li>Reviews and validates MCS Classicare members&rsquo; requests to determine eligibility for processing on the electronic platform, ensuring compliance with investigation protocols, evaluation standards, and timeliness requirements, following the company&rsquo;s Evidence of Coverage.</li><li>Document notes or chronology of CTM&rsquo;s, AOD&rsquo;s, and pre-service appeals investigations in the electronic platform to evidence proper management. This includes attachment of documentation related to the case and evidence of written notices to members or providers, based on the regulatory requirements.</li><li>Monitors CTM&rsquo;s and appeals processes to avoid impact on three (3) Stars metrics related to CTM, Appeals Timeliness, and Appeals Review (Upheld).</li><li>Supports in the unit rotation process by responding to inquiries related to pre-service appeals and AODs. Ensures appropriate referrals to other Departments for cases that do not qualify as appeals or AODs, assigns cases to relevant Specialists, and accurately updates internal logs and systems.</li><li>Responsible for overseeing the on-call program and monitoring processes related to the Unit. This includes supervision of corporate cell phone usage assigned to the Unit and ensuring timely access to staff by company personnel and regulatory agencies during and outside regular business hours, including evenings, weekends, and holidays. This is a regulated function that requires continuous availability and compliance with applicable regulatory requirements, to mitigate operational and compliance risks.</li><li>Complies with the delivery of data required by G&amp;A Analysts or immediate Supervisor to complete reports required by Regulatory Agencies, in the established timeframes and as requested (Example: CMS, ASES, OPP, OIC, other Departments, and/or MCS Units).</li><li>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.</li><li>May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.</li></ul>
MINIMUM QUALIFICATIONS 
Education and Experience: Bachelor&rsquo;s Degree in Business Administration, Finance, Social Services, or Criminal Justice. At least four (4) years of experience in the areas of Research, Auditing, or Client/Provider Service, preferred in the Healthcare Insurance Industry.
&ldquo;Proven experience may be replaced by previously established requirements.&rdquo;
Certifications / Licenses: N/A Other: Knowledge of the following systems is preferred: HPMS, PMHS, Beacon Healthcare System, and TruCare.
Languages:
Spanish &ndash; Advanced (comprehensive, writing and verbal)
English &ndash; Advanced (comprehensive, writing and verbal) 
&ldquo;We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.&rdquo;</div>

Especialista Senior De Querellas Y Apelaciones

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MCS HEALTHCARE HOLDINGS, LLC

About Company

Gerente De Manejo De Utilizacion

Evaluador(a) De Perfiles De Salud

Especialista Senior De Querellas Y Apelaciones