Preauthorization Nurse

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

Responsible for evaluating, identifying, and monitoring service requests of all line of business, making sure that they meet the criteria and deadlines established by CMS, ASES, OPM, URAC, among other regulatory agencies, and that they follow the protocols, policies and scripts of Triple-S Salud Inc. Improves the success of the organization by helping our members, providing high quality and efficient care when preauthorization are required.

WHAT YOU'LL DO

• Receives and evaluates service requests of all line of business.
• Coordinates services with providers and verifies that the service is offered following established protocols.
• Evaluates terms of coverage, quotes, codes, and changes of level. Negotiates rates and documents non-incurred expenses.
• Forwards all requests that do not meet eligibility benefit coverage, and medical necessity criteria to the medical advisor for determination.
• Perform/Support clinical appeals, referring them to the medical advisor if necessary.
• Ensuring dashboard is update and complying with timeframe establish by regulators.
• Verifies if requested codes are correct, according to the diagnostic or treatment required.
• Reviews the request to determine eligibility confirmation; benefit level verification; coordination of benefits; identification of benefit limitations/exclusions; appropriate provider, among others.
• Review of medical information and makes clinical decisions in accordance with established policies, criteria, guidelines, scripts or protocols. Utilizing standard criteria, protocols or guidelines as defined by the health plan and Medicare.
• Completes the request in the system and phones, faxes or mails a determination letter to the requesting provider and/or member as needed.
• Contacts policyholders and providers to notify them when a request has been resolved or when additional information is needed.
• Follows up on policyholders with rental equipment to determine when it’s time to pass from rent to buy.
• Documents all interventions related to a service request in the electronic application.
• Other tasks as assigned by the Management and that are essential.

WHAT YOU'LL BRING

Bachelor’s Degree (BD) in Nursing Sciences with one (1) to three (3) years of clinical experience in hospital field and/or in Preauthorization’s experience, preferable. Current/ Valid License in Nursing in Good Standing and without restrictions in Puerto Rico. Member of College of Nursing Professional of Puerto Rico.

CLOSING DATE: 05/19/2023

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