Especialista en Desarrollo de la Red

Especialista en Desarrollo de la Red

Regular

Exempt

GENERAL DESCRIPTION:

Evaluate and monitor the quality of service of the network to ensure that the service given by the providers is adequate. Maintains the Facility Provider Directory up to date and is responsible for preparing the corresponding communications. Guides and educates providers and department employees on manuals, laws, policies, procedures, and other topics that the company and regulatory agencies require.

ESSENTIAL FUNCTIONS:

• Discusses Performance Metrics reports with those providers as required by their contract.
• Prepares, coordinates, and provides guidance to new and existing providers related to MCS products, billing, claims processing, complaints, and grievances related to claims payment, model of care, and related processes, among others.
• Participates in meetings, activities, and training support to providers related to ICD-10, medical documentation, STARS, and Healthcare Effectiveness Data and Information Set (HEDIS), among others.
• Identifies Center for Medicaid and Medicare Services (CMS) charters, laws, and regulations, and/or any other supporting text or references that were used to develop and serve as references in the document.
• Facilitates, validates, and ensures that communications that are sent by delegated entities that mention or impact MCS meet the same standards and regulations as the letters that the company develops.
• Ensures completion of Care Model distribution and updating of demographic data quarterly per CMS requirements.
• Reports internal and external customer service quality surveys and evaluations.
• Supports the generation of educational material according to the annual provider education plan.
• Assist in the design and creation of educational materials and statements, according to regulations and CMS requirements.
• Oversees and applies the provider’s education work plan.
• Support the STARS Program. Assist in the progress of the work plans and STARS improvement initiatives. Organize and interpret current performance, yearly trends, and predicted performance of assigned metrics within the context of STARS Program compliance.
• Participates in strategic projects that will address the enhancement of the provider’s experience and growth while promoting the improvement of access to care, service, and quality.
• Establishes and complies with meeting schedules, both internal and external. Defines priorities and updates the schedule to ensure important or pending issues with providers are discussed and addressed within the established schedule.
• 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 in Business Administration, Health Services Administration, or related fields. At least two (2) years of experience managing healthcare provider interactions in customer service roles, including resolving inquiries and escalations, applying knowledge of healthcare insurance claims and grievance processes, and experience drafting professional documentation (letters, manuals, policies). Experience facilitating provider orientation, meetings, presentations, or training sessions is preferred.

“Proven experience may be replaced by previously established requirements.”

Certifications / Licenses: A Driver's License valid in the Commonwealth of Puerto Rico is required.

Other: Knowledge of medical billing. Basic knowledge of provider database systems. Familiarity with CMS regulations, provider communication standards, and compliance requirements related to provider education and network operations.

Languages:
Spanish – Intermediate (comprehensive, writing and verbal)
English – Intermediate (comprehensive, writing and verbal)

“We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.”