Guaynabo, PR

ABOUT US

At Grupo 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 Grupo 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

Monitor, coordinate, manage and assist in conducting periodic operational audits, caring out and performing operational compliance tests, preparing report of findings or results, make recommendations to the areas examined. Completes independently tasks that are guided by policies, procedures, and regulations. Responsible of compiling information based on facts, make analysis, and give monitor recommendations and action plans that will be used by others in another hierarchy level. Performs a variety of functions related to monitoring, identification, reporting, quality validation and accuracy of the payment of services from the health plan.

WHAT YOU'LL DO

• Monitor, coordinate, assist, manage and audit all tasks related to the consolidation of maximum out of pocket (C-MOOP) between Triple S and all delegated entities and employer Groups for Medicare Advantage and Commercial lines of business.
• Participate in special assignments such as, but not limited to; product periodic internal reviews or audits to ensure that operational procedures are followed.
• Select the best methodology to achieve identified results in a work plan or project.
• Design and run queries to obtain the required information for the audits and projects.
• Reports, prepare samples, working papers and any other document related to the work assigned.
• Gather and organize information on problems or procedures sufficient to execute the objectives of the monitoring assigned.
• Evaluate and recommend actions plans and/or procedures for the corporate/operational areas based on the audit findings.
• Work with external –carved out Pharmacy Benefit Manager (PBM).
• Work with delegated entities to ascertain that the data in the system is accurate.
• Manage internal and external referrals from Call Center, Service Centers, Groups, Auditors and Regulators.
• Request changes to the Technology Solutions, if necessary.
• Share best practices with other team members and ensure consistent handling of tasks.
• Assist in developing and improving existing processes and tools.
• Track and assist in issues regarding plan set up, benefit clarifications and benefit changes.
• Work with supervisor/manager to identify enhancements that would streamline processes.
• Analyze information gathered by investigation and report findings and recommendations as a written summary and/or presentation to related operational areas.
• Participate and provide technical advice on special projects of the division and/or corporation.
• Perform any other related tasks as requested by supervisor/manager or to cover the absence of other staff employees.
• Assist to program trainings in or out of Puerto Rico and/or via conference or travel as required.

WHAT YOU'LL BRING

Bachelor's Degree with one (1) to three (3) years of experience in claims processing. QNXT and exposed to audit experience within health insurance industry.

CLOSING DATE: 5/21/2023

It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, gender, 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 Minorities/Females/People with Disabilities/Veterans”. Employer with E-Verify to verify the eligibility of employment of all the new employees.

We encourage Females, Veterans and Disabled to Apply