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Claim specialist jobs in Puerto Rico - 28 jobs

  • Claims Specialist

    APS Health Care Pr 4.1company rating

    Claim specialist job in San Juan, PR

    Job Description The Claims Specialist (Auditor) position is responsible for assuring compliance with Medicaid, Commercial claims payment regulation. This position contributes to the identification and recovery of improper payments through management of claims audit timelines, billing, coding and payment analysis. Essential Functions: Conduct research and analysis utilizing claims and direct member reimbursement policies and procedures; the Center for Medicare and Medicaid Services (CMS) Manuals and pricing established for the Medicaid and commercial lines. Responsible for maintaining knowledge base of Medicaid and Commercial rules and regulations. Conduct claims and direct member reimbursements audits to evaluate compliance with Medicaid regulations and Commercial line. Responsible for identifying trends/concerns and conduct root cause analysis for identified concerns and document opportunities for improvement, make recommendations for process improvement, track, and trend performance for both claims analysts and claims process and develops trainings to address identified improvement opportunities. Evaluate the report where all the claims processed daily of the different products for the Medicaid and Commercial business lines sent by the supervisor are included. Able to work efficiently in teams and fluidly switch between team and self-directed work priorities. Coordinate with Claims, Information Technology, and other internal and external business partners to analyze and resolve data submission issues at the organization, provider, and regulator levels. Evaluate letters of denied claims and identify those that correspond to the development carried out by the Claims Department to be informed of Compliance. Reports possible instances of fraud and abuse, if found. Validation of the reimbursements worked by the Claims Department of the different products for the Medicaid and Commercial business lines. The Financial Recovery Claims Auditor will generate assessment reports monthly, quarterly, or as required. The Financial Recovery Claims Auditor will ensure: The charges listed on the invoice are correct. The services were paid according to the amount agreed upon in the service contract. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable. All other duties assigned by management. Education: Associate degree or four (2) years of experience in a directly related field Certification of compliance Medical Auditor, “CMA” Experience: Minimum three (3) years of claims processing with minimum two (2) years of claims auditing experience. Knowledge: Knowledgeable with insurance policy, Medicare regulations and general claim compliance Experience in CPT and ICD-10 coding and different pricing tools. Know several different coding systems, including Level 1 HCPCS and Level 2 HCPCS.
    $33k-40k yearly est. 1d ago
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  • Claims Representative (IAP) - Workers Compensation Training Program

    Sedgwick 4.4company rating

    Claim specialist job in San Juan, PR

    By joining Sedgwick, you'll be part of something truly meaningful. It's what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there's no limit to what you can achieve. Newsweek Recognizes Sedgwick as America's Greatest Workplaces National Top Companies Certified as a Great Place to Work Fortune Best Workplaces in Financial Services & Insurance Claims Representative (IAP) - Workers Compensation Training Program Are you looking for an impactful job requiring no prior experience that offers an opportunity to develop a professional career? + A stable and consistent work environment in an office setting. + A training program to learn how to help employees and customers from some of the world's most reputable brands. + An assigned mentor and manager who will guide you on your career journey. + Career development and promotional growth opportunities through increasing responsibilities. + A diverse and comprehensive benefits package to take care of your mental, physical, financial and professional needs. **PRIMARY PURPOSE OF THE ROLE:** To be oriented and trained as new industry professional with the ability to analyze workers compensation claims and determine benefits due. **ARE YOU AN IDEAL CANDIDATE?** We are seeking enthusiastic individuals for an entry-level trainee position. This role begins with a comprehensive 6-week classroom-based professional training program designed to equip you with the foundational skills needed for a successful career in claims adjusting. Over the course of a few years, you'll have the opportunity to grow and advance within the field. **ESSENTIAL RESPONSIBLITIES MAY INCLUDE** + Attendance and completion of designated classroom claims professional training program. + Performs on-the-job training activities including: + Adjusting lost-time workers compensation claims under close supervision. May be assigned medical only claims. + Adjusting low and mid-level liability and/or physical damage claims under close supervision. + Processing disability claims of minimal disability duration under close supervision. + Documenting claims files and properly coding claim activity. + Communicating claim action/processing with claimant and client. + Supporting other claims examiners and claims supervisors with larger or more complex claims as assigned. + Participates in rotational assignments to provide temporary support for office needs. **QUALIFICATIONS** Bachelor's or Associate's degree from an accredited college or university preferred. **EXPERIENCE** Prior education, experience, or knowledge of: - Customer Service - Data Entry - Medical Terminology (preferred) - Computer Recordkeeping programs (preferred) - Prior claims experience (preferred) Additional helpful experience: - State license if required (SIP, Property and Liability, Disability, etc.) - WCCA/WCCP or similar designations - For internal colleagues, completion of the Sedgwick Claims Progression Program **TAKING CARE OF YOU** + Entry-level colleagues are offered a world class training program with a comprehensive curriculum + An assigned mentor and manager that will support and guide you on your career journey + Career development and promotional growth opportunities + A diverse and comprehensive benefits offering including medical, dental vision, 401K, PTO and more _As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is 25.65/hr. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits. #claims #claimsexaminer #entrylevel #remote #LI-Remote_ Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace. **If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.** **Sedgwick is the world's leading risk and claims administration partner, which helps clients thrive by navigating the unexpected. The company's expertise, combined with the most advanced AI-enabled technology available, sets the standard for solutions in claims administration, loss adjusting, benefits administration, and product recall. With over 33,000 colleagues and 10,000 clients across 80 countries, Sedgwick provides unmatched perspective, caring that counts, and solutions for the rapidly changing and complex risk landscape. For more, see** **sedgwick.com**
    $31k-38k yearly est. 20d ago
  • Adjuster (Part-Time) - Cupey

    Popular Inc. 4.5company rating

    Claim specialist job in San Juan, PR

    Company: Popular Workplace Type: On-site Adjuster (Part-Time) - Cupey Job Type Part Time Opportunity - Monday through Saturday | 4:00pm-8:00pm * This job requires you to participate in training for eight consecutive weeks from 8:00 a.m. to 5:00 p.m. * This position also requires you to work sitting down and using telephone equipment all the time. * Flexibility to work weekends, extended hours, and holidays is also required if necessary. General Description Locates and notifies customers by telephone with delinquent accounts and attempts to secure payment. Essential Duties and Responsibilities * Contact customers by phone to encourage and secure payment of delinquent accounts. * Dialogue with customer by telephone in attempt to determine reason for overdue payment, reviewing terms of sales, service, or credit contract with customer. * Provides orientation to the customer concerning payment alternatives, debt restructuring, and obtaining a payment promise. * Follows up on payment promises. * Receives payments and posts the amount paid to the customer account. * Records information about the financial status of customers, updates demographic information, and the status of collection efforts. * Traces the customer to a new address by inquiring at the post office and other locations. Education 24 credits approved from a University or Accredited Institution or equivalent combination of education and experience. Experience At least one year of related experience in collections or customer service. Other Qualifications * Ability to identify the client's problems and necessities and offer different alternatives and solutions. * Excellent interpersonal skills and can work in groups. * Ability to manage difficult situations with clients. * Communication skills spoken and written in Spanish and English (preferred). * Ability to establish priorities and work on multiple tasks at the same time. * Ability to work under pressure and meet deadlines. * Customer service skills. * Knowledge of rules and regulations applicable to the collection of money. * Ability to influence others, reach agreements, and handle difficult situations with clients. Values 1. Passion for People 3. Succeed Together 2. Own Every Moment 4. Build the Future Important: The candidate must provide evidence of academic preparation or courses related to the job posting, if necessary. Our hybrid work model benefit applies to certain positions and is subject to changes based on the organizational needs. Applicants must be authorized to work for any employer in the United States. This position is not open to applicants who need visa sponsorship or transfer of visa sponsorship at this time. ABOUT US Popular is Puerto Rico's leading financial institution and have been evolving since it was founded over a century ago. From a small bank it has developed into a large corporation that offer a wide variety of services and financial solutions to our customers, with presence in the United States, the Caribbean and Latin America. As employees, we are dedicated to making our customers dreams come true by offering financial solutions in each stage of their life. Our extensive trajectory demonstrates the resiliency and determination of our employees to innovate, reach for the right solutions and strongly support the communities we serve; therefore, we value their diverse skills, experiences and backgrounds. We reaffirm our commitment to always offer essential financial services and solutions for our customers and communities, including during emergency situations and/or natural disasters. Popular's employees are considered essential workers, whose role is critical in the continuity of these important services even under such circumstances. By applying to this position, you acknowledge that Popular may require your services during and immediately after any such events. If you have a disability or need more information about requesting an accommodation, please contact us at ***************************. This email inbox is monitored for such types of requests only. All information you provide will be kept confidential and will be used only to the extent required to provide needed exemptions or reasonable accommodations. Any other correspondence will not receive a response. Are you ready for a rewarding career? Popular is an Equal Opportunity Employer, including Disability/Vets Learn more about us at *************** and keep updated with our latest job postings at ********************* Connect with us! LinkedIn | Facebook | Twitter | Instagram If you are a California resident, please click here to learn more about your privacy rights.
    $48k-60k yearly est. 7d ago
  • Accident & Health Claims Adjuster

    Chubb 4.3company rating

    Claim specialist job in San Juan, PR

    Role Purpose The Accident and Health Claims Adjuster is responsible to handle, investigate, analyze, calculate and approve insurance claims filed by policyholders and determine the extent of insurance company's liability concerning Accident and Health claims. Key Responsabilities Manage, evaluate and adjust Accident & Health claims as per the policy terms and conditions including application of exclusions if applicable. Work and manage as many fast track claims as possible (Medical Expenses) and analyze medical records. Assist in resolving complaints from policyholders relative to claims. Comply with OCS, PMP objectives, Claims Best Practices guidelines & standards of services as required. Do coverage determination position letters to policyholders. Perform specials projects and other related duties as assigned. Make timely decisions on claim approval, partial payment, or denial with clear justifications. Identify potential fraudulent claims and refer cases as necessary for investigation. Bachelor's Degree in Business Administration. Adjusters License from the Office of the Commissioner of Insurance of Puerto Rico (OCS). Demonstrated experience and/or knowledge in claims related to the following coverage's: Accident, Medical Expenses, Cancer, Critical Illnesses, Disability, Hospitalization, and SINOT, among others including policy interpretation. Strong ability to perform mathematical calculations. Demonstrate flexibility and adaptability to work in a fast moving and challenging environment. Proficient in MS Applications (Word, Excel and Power Point). Intermediate knowledge of the structure and content of the English and Spanish Language.
    $48k-56k yearly est. Auto-Apply 60d+ ago
  • Multi-Line Adjuster - Inside

    Crawford 4.7company rating

    Claim specialist job in Guaynabo, PR

    College degree or an equivalent combination of education and experience. Minimum 2 years insurance adjusting experience with experience in each of at least two lines of business (casualty, property, or marine). Personal computer, typing and keyboarding skills In-depth knowledge of insurance coverage, practices and negotiating skills in multiple lines of business. Familiarity with legal, medical and technical disciplines within specific business lines. Strong verbal and written communication skills. Good analytical ability and mathematical aptitude. Good attention to detail and organizational skills. Ability to gather and analyze information, then determine and implement the appropriate course of action. Good interpersonal skills. Licensing as required by state and local jurisdictions. Additional continuing education as required by Crawford Educational Services and as applicable for jurisdictions in which claims are adjusted or investigated. College degree or an equivalent combination of education and experience. Minimum 2 years insurance adjusting experience with experience in each of at least two lines of business (casualty, property, or marine). Personal computer, typing and keyboarding skills In-depth knowledge of insurance coverage, practices and negotiating skills in multiple lines of business. Familiarity with legal, medical and technical disciplines within specific business lines. Strong verbal and written communication skills. Good analytical ability and mathematical aptitude. Good attention to detail and organizational skills. Ability to gather and analyze information, then determine and implement the appropriate course of action. Good interpersonal skills. Licensing as required by state and local jurisdictions. Additional continuing education as required by Crawford Educational Services and as applicable for jurisdictions in which claims are adjusted or investigated. #LI-CB3 Investigate coverage, liability, and damages with all parties involved in a claim as requested by our customers or Crawford and Company or a subsidiary thereof. Investigate claims by interviewing claimants, witnesses, establish claim reserves, handle evidence, obtain and interpret official reports, medical reports and claim forms, and attend/participate at mediation, trials or hearings. Negotiates and settles claims, sets reserves, and manages litigation within client service parameters and authority levels by obtaining demands and making offers to claimants. May present evidence at legal proceedings. Provide filings with regulatory agencies, disposing of salvage and pursuing subrogation when appropriate. Prepare reports by collecting and summarizing information required by the client and obtained through investigation. Self starter capable of working alone or with others. Maintains company reputation and insurance product integrity by complying with Federal and state regulations, client and Crawford and Company service standards. Maintain expected case loads in multiple lines of business while meeting established service delivery, production, quality, sales and educational objectives. May be required to work on-call during off work hours to respond to emergency on-site investigations. Maintain professional and technical knowledge through continuing education in multiple lines of business. Maintain acceptable product quality through compliance with service standards and compliance with internal quality control initiatives. Uphold and project the corporate image by participating in industry organizations and functions. Ability to multi-task in a time sensitive environment and handle job responsibilities with a sense of urgency. Participates in special projects or performs duties in other areas as requested. Upholds the Crawford Code of Conduct.
    $49k-55k yearly est. Auto-Apply 60d+ ago
  • Claims Representative I (Health & Dental)

    Carebridge 3.8company rating

    Claim specialist job in San Juan, PR

    Claims Representative I Location Hybrid 1: This role requires associates to be in-office 1-2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Office Location: 654 Avenue Luis Munoz Rivera, San Juan, 00918 The Claims Representative I responsible for successfully completing the required basic training. Able to perform basic job functions with help from co-workers, specialists and managers on non-basic issues. Must pass the appropriate pre-employment test battery. How you will make an impact: * Learning the activities/tasks associated with his/her role. * Works under direct supervision. * Relies on others for instruction, guidance, and direction. * Work is reviewed for technical accuracy and soundness. * Codes and processes claims forms for payment ensuring all information is supplied before eligible payments are made. * Researches and analyzes claims issues. Minimum Requirements * HS diploma or equivalent and related experience; or any combination of education and experience which would provide an equivalent background. Preferred Skills, Capabilities and Experiences * Good oral and written communication skills, previous experience using PC, database system, and related software (word processing, spreadsheets, etc.) strongly preferred. * Familiarity with Medicare/Medicaid and claims. * Medical background (e.g., hospital or dental office experience). * Data entry experience. * Experience working with production goals. * Call center experience. Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ******************************************** for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
    $29k-36k yearly est. Auto-Apply 60d+ ago
  • Claim Support Specialist - PFML

    Metlife 4.4company rating

    Claim specialist job in San Juan, PR

    Location: Must live within a commutable distance of the Oriskany, NY, Tampa, FL, Bloomfield, CT Cary, NC, Aurora, IL, Bridgewater, NJ, Omaha, NE, Warwick, RI, Clark Summit, PA, San Juan, PR, West Des Moines, IA office Once a month in office for meetings How You'll Help Us Build a Confident Future (Key Responsibilities) * Coaches, coordinates, and develops Multi-State PFL, FML and ADA Claims Specialists. * Acts as resources for claim-related and technical issues. * Monitors case managers' work queues to ensure claims team is meeting expectations and applicable performance guarantees. * Conducts exceeds authority reviews daily, weekly quality audits; resolves escalated phone calls. * Analyzes trending opportunities to provide ongoing trainings. * Provides real time coaching to Claims Specialists. * Provides feedback to Unit Leaders on individuals' and overall team performance. * Daily and weekly reporting to ensure compliance measures are met. * Performs other related duties as assigned or required. What You Need to Succeed (Required Qualifications) * Positive mindset and willingness to learn. * 1+ years of Disability Insurance experience. * Must be able to communicate clearly and effectively, both written and verbal. * Ability to work with autonomy, minimal direction. * Strong computer skills (word, excel, manipulating reports, spreadsheets, etc...). * High School Diploma. What Can Give You an Edge (Additional Skills) * 1+ years of Paid Family Leave experience. * 5+ years of Disability Insurance experience. * Excellent analytical, decision making and problem-solving skills. * Highly self-motivated. Equal Employment Opportunity/Disability/Veterans If you need an accommodation due to a disability, please email us at accommodations@metlife.com. This information will be held in confidence and used only to determine an appropriate accommodation for the application process. MetLife maintains a drug-free workplace.
    $29k-33k yearly est. 20d ago
  • CSV Specialist

    QRC Group 4.3company rating

    Claim specialist job in Caguas, PR

    CSV Specialist to support the installation of several manufacturing solid dosage equipment such as but not limited to: Encapsulator Checkweigher Compression machine Hardness tester Encapsulation machine Auxiliary equipment Main activities should include: Verification of the equipment installed and configured at the vendor site (FAT). Implement the progression from FAT through IOQ in accordance with the CC strategy. Installation at the manufacturing room for qualification activities. Qualification activities in the manufacturing room areas. Development of Standard Operating Procedures. Generation and routing of calibration and preventive maintenance forms. Development and approval of GxP and automation impact assessments. Provide alternatives to resolve documentation situations. Establish project communication and documentation controls. Assure consistent quality of activities that meets or exceeds the requirements. Requirements Bachelor in Science or related field 2 -3 years of experience as CSV consultant in regulated industry. Experience with MS Office applications (Word, Excel and MS Project) Excellent technical writing skills. Bilingual: English and Spanish, speaking and writing.
    $63k-73k yearly est. 60d+ ago
  • CQV Specialist

    Mentor Technical Group 4.7company rating

    Claim specialist job in Puerto Rico

    Mentor Technical Group (MTG) provides a comprehensive portfolio of technical support and solutions for the FDA-regulated industry. As a world leader in life science engineering and technical solutions, MTG has the knowledge and experience to ensure compliance with pharmaceutical, biotechnology, and medical device safety and efficacy guidelines. With offices in Caguas, Puerto Rico, and Boston, United States, we serve life sciences clients in six global markets: United States, Puerto Rico, Dominican Republic, Mexico, Germany, Canada, and South America. Responsibilities: Collaborate with C&Q Engineers to develop and maintain commissioning and qualification procedures and documents. Write, review, and approve C&Q protocols and reports for various systems (e.g., HVAC, utilities, production equipment, lab equipment). Execute commissioning and qualification activities for plants and equipment. Coordinate with external consultants and internal resources to ensure timely document generation and execution. Manage change controls and deviations related to plants and equipment. Support maintenance and calibration functions to improve compliance and quality. Provide expertise in troubleshooting and root cause investigations. Facilitate the transfer of technical knowledge across units and sites. Qualifications Requirements/Knowledge/Education/Skills: Bachelor's or Master's degree in Chemical Engineering, Pharmaceutical Technology, or a related scientific field. At least 2 years of experience in GMP manufacturing relevant to the area of expertise. Proficiency in English; additional language skills are a plus. Strong understanding of regulatory requirements and quality standards. Excellent analytical, problem-solving, and communication skills. Ability to work collaboratively in a team environment. Mentor Technical Group es un empleador que ofrece igualdad de oportunidades y todos los solicitantes calificados recibirán consideración para el empleo sin importar raza, color, religión, sexo, orientación sexual, identidad de género, información genética, origen nacional, estado de veterano protegido, estado de discapacidad o cualquier otro grupo protegido por ley. Mentor Technical Group is an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, genetic information, national origin, protected veteran status, disability status, or any other characteristic protected by law.
    $55k-68k yearly est. Auto-Apply 60d+ ago
  • ERP Functional Specialist

    NTT America 4.8company rating

    Claim specialist job in San Juan, PR

    NTT DATA strives to hire exceptional, innovative and passionate individuals who want to grow with us. If you want to be part of an inclusive, adaptable, and forward-thinking organization, apply now. We are currently seeking a ERP Functional Specialist to join our team in San Juan, Puerto Rico (US-PR), United States (US). Overview of job: This is a 6 month position that will be responsible for providing business analysis, data cleanup, data validation and functional support to the Oracle PeopleSoft Financials application for the client. The position will also be responsible for enhancing Oracle PeopleSoft Financials functionality and reporting as well as maintaining integrity of existing functionality. This role is on client site. Job Responsibilities Include: * Perform business analysis and functional support for the Oracle PeopleSoft Financial application version 8.4. Functional areas include, but are not limited to, Billing, Accounts Receivable, Accounts Payable, and General Ledger. * Training users in the PeopleSoft application * Provide telephonic support to Oracle PeopleSoft Financial users * Financial Data Validation and Cleanup Basic Qualifications: * 4+ years of Accounting / Finance experience * 2+ years of functional experience with the following accounting modules: Billing, Accounts Receivable, Accounts Payable, and General Ledger * BBA accounting, finance or related degree * Bilingual ({Puerto Rican Spanish / English) * Selected candidate will be required to sit at the customer site in San Juan PR Preferred Skills: * Solid accounting background * Strong project, organizational and time management skills * Strong communication, interpersonal, analytical, and solid problem-solving skills. The role requires constant interaction with client subject matter experts About NTT DATA NTT DATA is a $30 billion business and technology services leader, serving 75% of the Fortune Global 100. We are committed to accelerating client success and positively impacting society through responsible innovation. We are one of the world's leading AI and digital infrastructure providers, with unmatched capabilities in enterprise-scale AI, cloud, security, connectivity, data centers and application services. our consulting and Industry solutions help organizations and society move confidently and sustainably into the digital future. As a Global Top Employer, we have experts in more than 50 countries. We also offer clients access to a robust ecosystem of innovation centers as well as established and start-up partners. NTT DATA is a part of NTT Group, which invests over $3 billion each year in R&D. Whenever possible, we hire locally to NTT DATA offices or client sites. This ensures we can provide timely and effective support tailored to each client's needs. While many positions offer remote or hybrid work options, these arrangements are subject to change based on client requirements. For employees near an NTT DATA office or client site, in-office attendance may be required for meetings or events, depending on business needs. At NTT DATA, we are committed to staying flexible and meeting the evolving needs of both our clients and employees. NTT DATA recruiters will never ask for payment or banking information and will only **************** ******************************* email addresses. If you are requested to provide payment or disclose banking information, please submit a contact us form, ************************************* NTT DATA endeavors to make ********************** accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact us at ************************************* This contact information is for accommodation requests only and cannot be used to inquire about the status of applications. NTT DATA is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. For our EEO Policy Statement, please click here. If you'd like more information on your EEO rights under the law, please click here. For Pay Transparency information, please click here.
    $63k-72k yearly est. Easy Apply 14d ago
  • Professional Review Specialist I

    Corvel Healthcare Corporation

    Claim specialist job in Guaynabo, PR

    Job Description The Professional Review Specialist analyzes medical services and billing across various claim types to evaluate the accuracy of charges and the medical necessity of care provided. This is a remote role. Candidate must be fully bilingual in English and Spanish. ESSENTIAL FUNCTIONS & RESPONSIBILITIES: Identify the necessity of the review process and communicate any specific issues of concern to the claims examiner/client and or direct reporting manager Collect supporting data and analyze information to make decisions regarding appropriateness of billing, delivery of care and treatment plans Appropriately document work and final conclusions in designated computer program Additional duties as assigned KNOWLEDGE & SKILLS: Thorough knowledge of ICD Diagnoses and Procedure Codes, and C.P.T., as well as an understanding of medical terminology Knowledge of applicable fee schedule and or applicable U&C Guidelines Proficient in Microsoft Office applications Technical aptitude with the ability to expand knowledge of MedCheck's proprietary systems Ability to work independently, follow process guidelines, and meet productivity standards and timelines (must maintain a score of 98% or higher on performance audits) EDUCATION & EXPERIENCE: Associate's degree or equivalent experience CPC or CPC-A required Previous experience in the following areas preferred: Medical bill auditing Knowledge of workers' compensation claims process Prospective, concurrent and retrospective utilization review PAY RANGE: CorVel uses a market based approach to pay and our salary ranges may vary depending on your location. Pay rates are established taking into account the following factors: federal, state, and local minimum wage requirements, the geographic location differential, job-related skills, experience, qualifications, internal employee equity, and market conditions. Our ranges may be modified at any time. For leveled roles (I, II, III, Senior, Lead, etc.) new hires may be slotted into a different level, either up or down, based on assessment during interview process taking into consideration experience, qualifications, and overall fit for the role. The level may impact the salary range and these adjustments would be clarified during the offer process. Pay Range: $18.80 - $30.34 per hour A list of our benefit offerings can be found on our CorVel website: CorVel Careers | Opportunities in Risk Management In general, our opportunities will be posted for up to 1 year from date of posting, or until we have selected candidate(s) to fulfill the opening, whichever comes first. ABOUT CORVEL: CorVel, a certified Great Place to Work Company, is a national provider of industry-leading risk management solutions for the workers' compensation, auto, health and disability management industries. CorVel was founded in 1987 and has been publicly traded on the NASDAQ stock exchange since 1991. Our continual investment in human capital and technology enable us to deliver the most innovative and integrated solutions to our clients. We are a stable and growing company with a strong, supportive culture and plenty of career advancement opportunities. Over 4,000 people working across the United States embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!). A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off. CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable. #LI-Remote
    $18.8-30.3 hourly 19d ago
  • Claims Examiner

    Harris Computer Systems 4.4company rating

    Claim specialist job in Florida, PR

    Responsibilities & Duties:Claims Processing and Assessment: * Evaluate incoming claims to determine eligibility, coverage, and validity. * Conduct thorough investigations, including reviewing medical records and other relevant documentation. * Analyze policy provisions and contractual agreements to assess claim validity. * Utilize claims management systems to document findings and process claims efficiently. Communication and Customer Service: * Communicate effectively with policyholders, beneficiaries, and healthcare providers regarding claim status and requirements. * Provide timely responses to inquiries and maintain professional and empathetic communication throughout the claims process. * Address customer concerns and escalate complex issues to senior claims personnel or management as needed. Compliance and Documentation: * Ensure compliance with company policies, procedures, and regulatory requirements. * Maintain accurate records and documentation related to claims activities. * Follow established guidelines for claims adjudication and payment authorization. Quality Assurance and Improvement: * Identify opportunities for process improvement and efficiency within the claims department. * Participate in quality assurance initiatives to uphold service standards and improve claim handling practices. * Collaborate with team members and management to implement best practices and enhance overall departmental performance. Reporting and Analysis: * Generate reports and provide data analysis on claims trends, processing times, and outcomes. * Contribute to the development of management reports and presentations regarding claims operations.
    $52k-60k yearly est. Auto-Apply 9d ago
  • Specialist Coordinator

    Bio-Nuclear of Puerto Rico

    Claim specialist job in San Juan, PR

    Job Description: GENERAL POSITION INFORMATIONJOB TITLE: Applications Specialists CoordinatorDEPARTMENT / UNIT: Applications SpecialistsIMMEDIATE SUPERVISOR: Applications Specialists SupervisorCLASSIFICATION: Non-Exempt POSITION NATURE Provide administrative support and coordinate certain processes related to the daily operations of the Applications Specialists department. ESSENTIAL DUTIES AND RESPONSIBILITIESReceive information from other departments, channel it to the Applications Specialists for analysis, and ensure the operational area receives a response to their request. Create, assign, coordinate, invoice, and close the department's service calls in Salesforce. Prepare quotations for products and services requested by clients and provide necessary follow-up for approval and/or changes. Invoice products and services in Acumatica according to client-approved quotations. Provide guidance regarding the company's products and services to existing and prospective clients. Verify supplier website information to keep technical documents, such as Inserts and Safety Data Sheets, updated for client provision. Maintain and update in Excel the inventory of loaner equipment and their exact locations. Ensure the department is stocked with necessary office supplies. Reserve and oversee the proper use of meeting and training rooms: “Theoretical Training Room” and “Hands-On Training Room. ”Coordinate department-sponsored activities and training sessions following the activity coordination procedure, including but not limited to preparing literature, giveaways, ordering and managing meals and refreshments, and arranging parking. Update and submit monthly reports on product lines and equipment handled by the Applications Specialists to the Applications Specialists Supervisor and Senior Strategic Service Manager. Perform departmental administrative tasks, including but not limited to making and answering phone calls, taking and referring messages, copying, digitizing and filing documents, distributing and handling correspondence, among others. Actively contribute to maintaining the company's mission and achieving its vision; exemplify through performance and conduct the efficiency culture, Bionuclear's values, and principles of the highest quality internal and external customer service. INCIDENTAL DUTIES AND RESPONSIBILITIESLabel and prepare tubes for aliquot processing as needed. Coordinate equipment shipments requiring manufacturer repair through an external courier. Support the Administration department by covering the Reception area during the receptionist's break or as needed. Support the Project Management department by covering the Project Management Specialist as needed. Perform tasks related to coordinating official activities approved by the immediate supervisor in support of other departments. Prepare department statistics reports as requested. Review and send training certificates prepared by the Specialists to clients. Perform administrative tasks in support of other departments, such as Technical Services and Project Management. Coordinate meals and snacks for employee, client, supplier, and visitor activities organized by the company, on or off-site, and coordinate pick-up with the Administration department. Gather information for presentations or reports requested by the Supervisor or Senior Strategic Service Manager. Create reports/dashboards in Salesforce as requested by the supervisor. Coordinate, receive, and attend to visitors. Contact clients to complete service satisfaction surveys using the Forms platform. Perform operational tasks as delegated to fulfill action plans of the Senior Strategic Service Manager. Send data to be processed by external resources as assigned by the Applications Specialists Supervisor and/or Senior Strategic Service Manager. Contact the Buyer for information on backordered products. Contact the Audit supplier to gather information regarding product availability. Maintain updated information on Applications Specialists and suppliers in the OneDrive folder named Supplier Directory. Create equipment installed by the Applications Specialists in the Salesforce platform. Coordinate, attend, and/or participate in work meetings, operational and/or corporate committees, personnel development activities, corporate events, among others. Make flight and hotel reservations for the Specialists group as needed. Perform other tasks as assigned. EDUCATIONAL BACKGROUND Associate's degree or two years of university studies in Business Administration, Office Administration, Secretarial Studies, or a related field. PROFESSIONAL EXPERIENCE Minimum of more than one year of experience performing functions in a similar position. JOB COMPETENCIES KNOWLEDGE, SKILLS, ABILITIES, AND ATTRIBUTES REQUIRED TO PERFORM THE JOBExcellent customer service skills (both external and internal) Strong sense of urgency Ability to interact professionally with individuals at all organizational levels Attention to detail and ability to identify errors and omissions Teamwork skills Ability to work under deadlines and pressure Ability to handle multiple tasks simultaneously Results-oriented Good emotional intelligence Professional, courteous, and friendly demeanor Strong verbal and written communication skills in English and SpanishProficiency in Windows applications (Word, Excel, Outlook, and PowerPoint) Availability to work on holidays, weekends, and extended hours DISCLAIMER CLAUSE The information provided herein summarizes the general nature of the competencies and the level of complexity of the functions established for personnel in this position. Its content should not be interpreted as an exhaustive inventory of all the duties, tasks, and responsibilities of the position. Other tasks may be added, or existing tasks may be modified as stipulated by the company. We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities. Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, pregnancy, sexual orientation, gender identity, national origin, age, protected veteran status, or disability status. EEO/Affirmative Action for Veterans/Workers with Disabilities Datos generales del puesto Coordinador de Especialistas de Aplicaciones Especialistas de Aplicaciones Supervisor de Especialista de Aplicaciones No exento Naturaleza del puesto Dar apoyo administrativo y coordinar ciertos procesos propios a las operaciones diarias del departamento de Especialistas de Aplicaciones. Deberes y responsabilidades esenciales del puesto Recibir la información proveniente de otros departamentos, canalizando la misma con los Especialistas de Aplicaciones para su análisis y asegurar que el área operacional reciba la respuesta a su solicitud. Crear, asignar, coordinar, facturar y cerrar las llamadas de servicio del departamento en Sales Force. Preparar cotizaciones de productos y servicios solicitados por los clientes y brindar el seguimiento necesario a los clientes para aprobación y/o cambios. Facturar en Acúmatica productos y servicios según las cotizaciones aprobadas por los clientes. Proveer orientación acerca de los servicios y productos ofrecidos por la compañía a clientes existentes y prospectivos. Verificar la información de la página web de los suplidores, para mantener la información actualizada de los documentos técnicos como: “Inserts” y “Safety Data Sheets” para proveerlos a los clientes. Llevar un registro en Excel y su actualización del inventario de los equipos prestados (“loaners”) y sus ubicaciones exactas. Mantener abastecido el departamento de los materiales de oficina necesarios. Reservar y velar por el buen uso de los salones de reunión y adiestramientos: “Theorical Training Room” y “Hands On Training Room”. Coordinar las actividades y adiestramientos auspiciados por el departamento de Especialistas de Aplicaciones, siguiendo el procedimiento de coordinación de actividades. Incluyendo, pero no limitándose a, la preparación de literatura, “giveaways”, ordenar y gestionar las comidas y refrigerios, estacionamiento. Actualizar y someter mensualmente el informe de líneas de productos y equipos trabajados por las Especialistas de Aplicaciones a la Supervisora de Especialista de Aplicaciones y Gerente Senior de Servicio Estratégico. Realizar el trabajo administrativo del departamento, lo que incluye, pero no se limita a, generar y contestar llamadas telefónicas, tomar y referir mensajes, sacar copias, digitalizar y archivar documentos, distribuir y manejar la correspondencia, entre otros. Aportar activamente al mantenimiento de la misión y al logro de la visión de la compañía; y ejemplificar con su desempeño y conducta la filosofía de la cultura de eficiencia, los valores de Bionuclear y los principios de un servicio al cliente interno y externo de la más alta calidad. Deberes y responsabilidades incidentales del puesto Rotular y preparar los tubos para el procesamiento de las alícuotas según la necesidad Gestionar a través de un carrero externo el envío de los equipos que necesitan reparación del manufacturero. Brindar apoyo al departamento de Administración cubriendo la Recepción durante el período de tomar alimentos de la Recepcionista o según se presente la necesidad. Brindar apoyo al departamento de Gerencia de Proyecto cubriendo a la Especialista de Gerencia de Proyecto según se presente la necesidad. Realizar tareas propias a la coordinación de actividades oficiales y aprobadas por el supervisor inmediato en apoyo a otros departamentos. Preparar informes sobre las estadísticas del departamento según sea solicitado. Revisar y enviar los certificados de adiestramientos preparados por los Especialistas a los clientes. Realizar tareas administrativas como apoyo a otros departamentos como lo son: Servicios Técnicos y Gerencia de Proyectos. Coordinar los alimentos y meriendas para las actividades de empleados, clientes, suplidores y visitantes que realice la compañía, en o fuera de sus instalaciones físicas y coordinar el recogido con el departamento de Administración. Recopilar información para presentaciones o reportes solicitado por la supervisora o Gerente Sénior de Servicio Estratégico. Crear reportes/dashboards en Sales Force solicitado por el supervisor. Coordinar, recibir y atender visitas. Contactar al cliente para completar las encuestas de satisfacción en el servicio utilizando la plataforma de Forms. Realizar tareas operacionales según se le delegue para el cumplimiento de los planes de acción del Gerente Senior de Servicio Estratégico. Enviar la data a ser trabajada por recursos externos según asignado por la Supervisora de Especialistas de Aplicaciones y/o la Gerente Sénior de Servicio Estratégico. Contactar al Comprador para obtener información de los productos en “Back orders”. Contactar al suplidor Audit para recopilar la información relacionada sobre la disponibilidad de los productos. Mantener actualizada la información de los Especialistas de Aplicaciones y suplidores en la carpeta denominada Directorio de suplidores en One Drive. Crear los equipos que instalen los Especialista de Aplicaciones en la plataforma de Salesforce. Coordinar, asistir y/o participar en reuniones de trabajo, comités operacionales y/o corporativos, actividades de desarrollo de personal, eventos corporativos, entre otros. Realizar reservaciones de vuelos y hoteles para el grupo de Especialistas según sea necesario. Otras tareas, que le sean asignadas. Preparación académica Grado Asociado o dos años universitarios en Administración de Empresas, Administración de Oficinas, Secretarial o campo relacionado. Experiencia Profesional Experiencia mínima de más de un año realizando funciones en un puesto similar. Competencias del trabajo Conocimientos, destrezas, habilidades y aptitudes necesarias para desempeñar el puesto Excelentes destrezas de servicio al cliente (externo e interno) Gran sentido de urgencia Habilidad para relacionarse profesionalmente con personas de todos los niveles jerárquicos Atención al detalle y capacidad para detectar errores y omisiones Habilidad para trabajar en equipo Habilidad para trabajar con fechas límites y bajo presiónHabilidad para trabajar varias tareas simultáneamente Habilidad para lograr resultados Buen manejo de sus emociones Proyección profesional, cordial y amable Buenas destrezas de comunicación verbal y escrita en inglés y español Dominio de las aplicaciones de Windows (Word, Excel, Outlook y PowerPointDisponibilidad para trabajar días feriados, fines de semana y horarios extendidos Cláusula de salvedad La información aquí contenida resume la naturaleza general de las competencias y el grado de complejidad de las funciones establecidas para el personal que desempeña este puesto. Su contenido no debe interpretarse como un inventario exhaustivo de todas las funciones, tareas y responsabilidades del puesto. Otras tareas podrían ser añadidas o las existentes podrían ser modificadas según lo estipule la compañía. Somos un patrono con Igualdad de Oportunidades en el Empleo y tomamos acción afirmativa para reclutar Veteranos(as) Protegidos(as) y Personas con Discapacidad. Patrono con igualdad de oportunidades en el empleo. Todos(as) los(las) solicitantes calificados(as) recibirán consideración para empleo sin distinción de raza, color, religión, sexo, embarazo, orientación sexual, identidad de género, origen nacional, edad, estatus como veterano(a) protegido(a) o discapacidad física o mental. IOE/Acción Afirmativa para Veteranos(as)/Personas con Discapacidad.
    $44k-50k yearly est. 9d ago
  • HSE Specialist I

    Fluor 4.5company rating

    Claim specialist job in Puerto Rico

    At Fluor, we are proud to design and build projects and careers. We are committed to fostering a welcoming and collaborative work environment that encourages big-picture thinking, brings out the best in our employees, and helps us develop innovative solutions that contribute to building a better world together. If this sounds like a culture you would like to work in, you're invited to apply for this role. Fluor is a leading government contractor with a proven track record of delivering high‑value technical solutions around the world to U.S. government agencies such as the DOE, NNSA, the Department of Defense and the Intelligence Community. **Job Description** The purpose of this position to apply recently gained education or experience to promote a safe work environment. These problems include but are not limited to prevention of human injury, environmental degradation and unsafe working conditions/practices. This is done through health, safety and environmental training, programs, and processes with a visible and uncompromised commitment to the protection of the environment as well as the productivity of the Company's employees. - Promote HSE standards and goals with programs throughout the Company and/or project to foster a safe and productive work environment - Assist with the administration of simple HSE programs involving lower levels of employees on the project or in the office through presentations, printed materials, and activities - Provide support in the development of simple HSE project plans and development of simple HSE specifications - Using established procedures, assist in the preparation of surveys, audits, evaluations, inspections, and investigations of incidents and activities to monitor and track HSE standards, programs and goals including project environmental data collection and documentation - Adhere to and support Fluor's Health, Safety & Environmental and Sustainability Policies - Other duties as assigned **Basic Job Requirements** - Accredited four (4) year degree or global equivalent in applicable field of study and no required years of work-related experience or a combination of education and directly related experience equal to four (4) years if non-degreed; some locations may have additional or different qualifications in order to comply with local requirements - Ability to communicate effectively with audiences that include but are not limited to management, coworkers, clients, vendors, contractors, and visitors - Job related technical knowledge necessary to complete the job - Ability to learn and apply knowledge of applicable local, state/province, and federal/national statutes and guidelines - Ability to attend to detail and work in a time-conscious and time-effective manner **Other Job Requirements** - Gather industry-wide HSE-related information and data for application to HSE programs and procedures - Occasionally assist with the activities of subordinates when requested by supervisor **Preferred Qualifications** - Basic computer and software skills to include the use of word processing and email as well as the intermediate use of spreadsheets and electronic presentations We are an equal opportunity employer. All qualified individuals will receive consideration for employment without regard to race, color, age, sex, sexual orientation, gender identity, religion, national origin, disability, veteran status, genetic information, or any other criteria protected by governing law. Benefits Statement: Fluor is proud to offer a comprehensive benefits package designed to promote employee health, wellness, and financial security. Our offerings include medical, dental and vision plans, EAP, disability coverage, life insurance, AD&D, voluntary benefit plans, 401(k) with a company match, paid time off (personal, bereavement, sick, holidays) for salaried employees, paid sick leave per state requirement for craft employees, parental leave, and training and development courses. Market Rate Statement: The market rate for the role is typically at the mid-point of the salary range; however, variations in final salary are determined by additional factors such as the candidate's qualifications, relevant years of experience, geographic location, internal pay equity, and prevailing market conditions for the specific role. Notice to Candidates: Background checks are carried out as part of any conditional offer made, including (but not limited to & role dependent) education, professional registration, employment, references, passport verifications and Global Watchlist screening. To be Considered Candidates: Must be authorized to work in the country where the position is located. Salary Range: $38,000.00 - $65,000.00
    $38k-65k yearly 35d ago
  • ERP Functional Specialist

    NTT Data North America 4.7company rating

    Claim specialist job in San Juan, PR

    **Req ID:** 351726 NTT DATA strives to hire exceptional, innovative and passionate individuals who want to grow with us. If you want to be part of an inclusive, adaptable, and forward-thinking organization, apply now. We are currently seeking a ERP Functional Specialist to join our team in San Juan, Puerto Rico (US-PR), United States (US). **Overview of job** **:** This is a **6 month position** that will be responsible for providing business analysis, data cleanup, data validation and functional support to the Oracle PeopleSoft Financials application for the client. The position will also be responsible for enhancing Oracle PeopleSoft Financials functionality and reporting as well as maintaining integrity of existing functionality. This role is on client site. **Job Responsibilities Include:** + Perform business analysis and functional support for the Oracle PeopleSoft Financial application version 8.4. Functional areas include, but are not limited to, Billing, Accounts Receivable, Accounts Payable, and General Ledger. + Training users in the PeopleSoft application + Provide telephonic support to Oracle PeopleSoft Financial users + Financial Data Validation and Cleanup **Basic Qualifications** **:** + 4+ years of Accounting / Finance experience + 2+ years of functional experience with the following accounting modules: Billing, Accounts Receivable, Accounts Payable, and General Ledger + BBA accounting, finance or related degree + Bilingual ({Puerto Rican Spanish / English) + Selected candidate will be required to sit at the customer site in San Juan PR **Preferred Skills** **:** + Solid accounting background + Strong project, organizational and time management skills + Strong communication, interpersonal, analytical, and solid problem-solving skills. The role requires constant interaction with client subject matter experts **About NTT DATA** NTT DATA is a $30 billion business and technology services leader, serving 75% of the Fortune Global 100. We are committed to accelerating client success and positively impacting society through responsible innovation. We are one of the world's leading AI and digital infrastructure providers, with unmatched capabilities in enterprise-scale AI, cloud, security, connectivity, data centers and application services. our consulting and Industry solutions help organizations and society move confidently and sustainably into the digital future. As a Global Top Employer, we have experts in more than 50 countries. We also offer clients access to a robust ecosystem of innovation centers as well as established and start-up partners. NTT DATA is a part of NTT Group, which invests over $3 billion each year in R&D. Whenever possible, we hire locally to NTT DATA offices or client sites. This ensures we can provide timely and effective support tailored to each client's needs. While many positions offer remote or hybrid work options, these arrangements are subject to change based on client requirements. For employees near an NTT DATA office or client site, in-office attendance may be required for meetings or events, depending on business needs. At NTT DATA, we are committed to staying flexible and meeting the evolving needs of both our clients and employees. NTT DATA recruiters will never ask for payment or banking information and will only **************** ******************************* email addresses. If you are requested to provide payment or disclose banking information, please submit a contact us form, ************************************ . **_NTT DATA endeavors to make_** **_************************* **_accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact us at_** **_************************************_** **_._** **_This contact information is for accommodation requests only and cannot be used to inquire about the status of applications. NTT DATA is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. For our EEO Policy Statement, please click here (***************************************** . If you'd like more information on your EEO rights under the law, please click here (***************************************************** . For Pay Transparency information, please click here (***************************************** ._**
    $71k-83k yearly est. Easy Apply 14d ago
  • Professional Review Specialist I

    Corvel 4.7company rating

    Claim specialist job in Guaynabo, PR

    The Professional Review Specialist analyzes medical services and billing across various claim types to evaluate the accuracy of charges and the medical necessity of care provided. This is a remote role. Candidate must be fully bilingual in English and Spanish. ESSENTIAL FUNCTIONS & RESPONSIBILITIES: * Identify the necessity of the review process and communicate any specific issues of concern to the claims examiner/client and or direct reporting manager * Collect supporting data and analyze information to make decisions regarding appropriateness of billing, delivery of care and treatment plans * Appropriately document work and final conclusions in designated computer program * Additional duties as assigned KNOWLEDGE & SKILLS: * Thorough knowledge of ICD Diagnoses and Procedure Codes, and C.P.T., as well as an understanding of medical terminology * Knowledge of applicable fee schedule and or applicable U&C Guidelines * Proficient in Microsoft Office applications * Technical aptitude with the ability to expand knowledge of MedCheck's proprietary systems * Ability to work independently, follow process guidelines, and meet productivity standards and timelines (must maintain a score of 98% or higher on performance audits) EDUCATION & EXPERIENCE: * Associate's degree or equivalent experience * CPC or CPC-A required * Previous experience in the following areas preferred: * Medical bill auditing * Knowledge of workers' compensation claims process * Prospective, concurrent and retrospective utilization review PAY RANGE: CorVel uses a market based approach to pay and our salary ranges may vary depending on your location. Pay rates are established taking into account the following factors: federal, state, and local minimum wage requirements, the geographic location differential, job-related skills, experience, qualifications, internal employee equity, and market conditions. Our ranges may be modified at any time. For leveled roles (I, II, III, Senior, Lead, etc.) new hires may be slotted into a different level, either up or down, based on assessment during interview process taking into consideration experience, qualifications, and overall fit for the role. The level may impact the salary range and these adjustments would be clarified during the offer process. Pay Range: $18.80 - $30.34 per hour A list of our benefit offerings can be found on our CorVel website: CorVel Careers | Opportunities in Risk Management In general, our opportunities will be posted for up to 1 year from date of posting, or until we have selected candidate(s) to fulfill the opening, whichever comes first. ABOUT CORVEL: CorVel, a certified Great Place to Work Company, is a national provider of industry-leading risk management solutions for the workers' compensation, auto, health and disability management industries. CorVel was founded in 1987 and has been publicly traded on the NASDAQ stock exchange since 1991. Our continual investment in human capital and technology enable us to deliver the most innovative and integrated solutions to our clients. We are a stable and growing company with a strong, supportive culture and plenty of career advancement opportunities. Over 4,000 people working across the United States embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!). A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off. CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable. #LI-Remote
    $18.8-30.3 hourly 18d ago
  • CSV Specialist

    Mirus Consulting Group

    Claim specialist job in Gurabo, PR

    mîrus Consulting Group is a local company based in Humacao, Puerto Rico that provides computer system validation and information technology consulting services to pharmaceutical companies and other organizations across the Island and parts of the United States. Its services include the assessment and validation of automation equipment, network infrastructures and business processes, as well as the project management involved. Position Summary: The CSV Specialist will be responsible for managing and executing all activities related to Computer System Validation (CSV) throughout the full validation lifecycle, ensuring compliance with FDA, cGMP, 21 CFR Part 11, GAMP 5, and corporate standards. This position will support system implementations, upgrades, and periodic reviews across manufacturing and quality systems, with a strong focus on parenteral processes and regulated environments. Key Responsibilities: Develop, review, and execute CSV deliverables including Validation Plans, Risk Assessments, URS, FRS, IQ/OQ/PQ protocols, and Validation Summary Reports. Ensure that computerized systems meet data integrity and regulatory compliance requirements. Support system implementations, migrations, and upgrades, collaborating closely with IT, QA, and Manufacturing teams. Participate in impact assessments, change control activities, and periodic system reviews. Provide technical and compliance support during internal and external audits. Maintain validation documentation in alignment with company quality systems and GAMP 5 guidance. Support troubleshooting, deviation resolution, and CAPA implementation related to validated systems. Promote continuous improvement and standardization of CSV practices across site operations. Qualifications & Requirements: Bachelor's Degree in engineering, Computer Science, or a related scientific discipline. Minimum of 5 years of hands-on experience in Computer System Validation within the pharmaceutical or biotechnology industry. Strong knowledge of CSV lifecycle methodology, 21 CFR Part 11, Annex 11, and GAMP 5. Experience with parenteral operations or aseptic manufacturing environments preferred. Excellent documentation, communication, and teamwork skills. Fully bilingual (Spanish/English) preferred. This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications. ***************
    $44k-50k yearly est. 43d ago
  • Crop Claims Seasonal Adjuster

    Great American Insurance Group (DBA 4.7company rating

    Claim specialist job in Florida, PR

    Be Here. Be Great. Working for a leader in the insurance industry means opportunity for you. Great American Insurance Group's member companies are subsidiaries of American Financial Group. We combine a "small company" culture where your ideas will be heard with "big company" expertise to help you succeed. With over 30 specialty and property and casualty operations, there are always opportunities here to learn and grow. At Great American, we value and recognize the benefits derived when people with different backgrounds and experiences work together to achieve business results. Our goal is to create a workplace where all employees feel included, empowered, and enabled to perform at their best. The Crop Division of Great American has been helping generations of farmers take control of their risks since 1915. The Division is also one of a select few private companies authorized by the United States Department of Agriculture Risk Management Agency (USDA RMA) to write MPCI policies. With six regional offices throughout the U.S., the teams provide tremendous expertise in the specific needs of farmers and crops. ********************************** Great American is currently seeking Seasonal Crop Adjusters. These positions are seasonal and may not be eligible for full-time or part-time benefits. Qualified candidates will cover territory in one of the following states: * Alabama * Arkansas * California * Colorado * Florida * Georgia * Idaho * Illinois * Indiana * Iowa * Kansas * Kentucky * Louisiana * Michigan * Minnesota * Mississippi * Missouri * Montana * Nebraska * New York * North Carolina * North Dakota * Ohio * Oklahoma * Oregon * Pennsylvania * South Carolina * South Dakota * Tennessee * Texas * Washington * Wisconsin * Wyoming Schedule: Seasonal part-time. Hours fluctuate based on seasonal needs. As a Crop Adjuster, you will: * Understand and can work claims for all major crops, policy/plan types, in all stages of growth. * Complete field inspections, reviews, and adjustments by reading maps and aerial photos, measuring fields and storage bins, and appropriately administering company Crop insurance policies. * Review and evaluates coverage and/or liability. * Secure and analyze necessary information (i.e., reports, policies, appraisals, releases, statements, records, or other documents) in the investigation of claims. * Ensure compliant and cost effective application of Crop policies by leveraging knowledge of basic insurance statutes and regulations and complying with state and federal regulatory requirements. * Accurately document, process and transmit loss information to determine potential. * Works toward the resolution of claims files, and may attend arbitrations, mediations, depositions, or trials as necessary. * May affect settlements/reserves within prescribed limits and submit recommendations to supervisor on cases exceeding personal authority. * Conveys simple to moderately complex information (coverage, decision, outcomes, etc.) to all appropriate parties, maintaining a professional demeanor in all situations. * Ensures that claims handling is conducted in compliance with applicable statues, regulations, and other legal requirements, and that all applicable company procedures and policies are followed. * Follow regulatory and company rules, policies, and procedures. * Performs other duties as assigned. Physical Requirements for employees in the Crop Business Unit/Crop Claims General Adjuster * Requires continuous and prolonged walking and standing. * Requires frequent lifting, carrying, pushing and pulling of objects up to 50 lbs. * Requires frequent climbing grain bins, bending, twisting, stooping, kneeling and crawling. * Requires overhead reaching and grabbing. * Requires regular and predictable attendance. * Requires ability to conduct visual inspections. * Requires work outdoors, in inclement weather conditions. * Requires frequent travel. * May require ability to operate a motor vehicle. Business Unit: Crop Salary Range: $0.00 -$0.00 Benefits: Compensation varies by role, position level, and location. Individual pay is influenced by skills, education, training, certifications, experience, and the role's scope and complexity, along with business needs. We offer a competitive Total Rewards package, including medical, dental, and vision plans starting on day one, PTO, paid holidays, commuter benefits, an employee stock purchase plan, education reimbursement, paid parental leave/adoption assistance, and a 401(k) plan with company match. These benefits are available to eligible full-time and part-time employees. Your recruiter can provide more details about our total rewards and specific compensation ranges during the hiring process.
    $48k-55k yearly est. Auto-Apply 60d+ ago
  • CSV Specialist

    Flexible & Integrated Technical Services

    Claim specialist job in Barceloneta, PR

    For Computer and System Validation services in the Engineering area. WHAT MAKES YOU A FIT: The Technical Part: Bachelor's degree in engineering or science with five (5) years of experience in computerized system validation of the pharmaceutical or biopharmaceutical industry. Experience in: Design and execution of compliant and efficient validation strategies for system and equipment. Development of a technically competent and focused customer service-oriented team. Ensure that timely and adequate computerized system validation is performed in conformance with cGMP's plant procedures, corporate policies, and applicable regulations (FDA, ENEA, DEA, etc.) Prioritizes projects and schedules as needed. Provides guidance for determining work procedures, preparation of work schedule, and expediting of workflow. The Personality Part: Besides being an CSV Pro, you're able to analyze data so that not a single inconsistency gets past you (which allows you to be an amazing problem-solver). You're also a skilled multitasker with an incredible ability to set priorities. Add to this a commitment to serving customers with high-quality research and products, to embracing a diverse work culture, and even to the environment, and you might just be what we're looking for! AS A PIECE OF FITS, YOU WILL: (The day-to-day on the job) Define and execute strategies for IT Computerized Systems, Computerized System Validation and Data Integrity Compliance for Computerized Systems. Design and execute Validation Plans and Protocols for Computerized Systems. Perform data integrity risk assessment for new and existing computerized systems. Execute Periodic Review activities for the Computerized System in adherence with Site, Regulatory, and Client Corporate Requirements. Work both independently and in a team environment with representatives from Quality, Engineering, Manufacturing Operations, and Manufacturing Science & Technology. Work within the Office Environment and GMP Controlled Cleanrooms. Work within a Facility that requires high diligence and, on occasion, use Personal Protective Equipment (PPE) effectively. Coordinate and execute activities as per the approved Protocol. Perform computerized systems validation in conformance with cGMPs, plan procedures, corporate policies, and applicable regulations (FDA, DEA, etc.) WHO WE ARE: We are a Service Provider company different from the rest. We pride ourselves in how we treat the most important piece of our company's puzzle: you! We integrate Engineering, Construction, Maintenance, Utilities and Specialized Technical services across the Island (and in the US as well!). Our company is flexible, family-oriented and focused on our resources' well-being, while providing our Pharmaceutical, Medical Device and Manufacturing industry clients with top-notch quality talent. We're FITS! Are you the next piece?
    $44k-50k yearly est. Auto-Apply 50d ago
  • Airfield Runway Specialist

    Hi-Lite Airfield Services 3.4company rating

    Claim specialist job in Carolina, PR

    Who We Are: Hi-Lite is a Best-in-Class organization. We are the leader in airfield rubber and paint removal, surface preparation, crack seal, and pavement maintenance. Starting wage: $15.00 Working with the Best: Hi-Lite Airfield Services, LLC is a first class organization for someone interested in a career in airport markings and maintenance. Our personnel include people who have started work as laborers and risen to management status, as well as those who have had previous experience with similar firms in our industry. We offer a full range of benefits such as medical and dental insurance, paid holidays, 401 K match, paid training and other benefits. We are a people powered organization, our people come first and our culture matters. What We Offer: Hi-Lite offers generous compensation, including: $15.00/hour to start while working on airfield. Great benefits include health insurance options, 401K with match, paid time off, and a Christmas bonus. Hi-Lite pays for your airfare to/from job sites, hotel costs, and provides per diem for food Starting Pay Depending on Experience for proven operators What Hi-Lite Expects From You: Ability to travel overnight Good attendance Willingness to learn Work Authorization/Security Clearance: 10-year criminal background search Meet badging requirements at all airports Pre-employment drug screen Valid Driver's License with clean driving history - must be a Real ID Social Security Card What You Will Do: Drive and operate equipment including a forklift, grinder, bobcat, hand striping equipment, blowers, and pickup trucks. Perform a variety of tasks involving strenuous manual labor in heavy/airport construction projects; perform manual work in preparing surfaces for striping and maintenance. Moving stencils, and duct-taping to prepare for painting. Maintenance and protection of traffic. Maintain a clean job site: pick up all tools and equipment and secure the job site each day to eliminate potential hazards. Material handling and storage. Must be able to lift a minimum of 50 lbs. Load and unload trucks and haul and hoist materials. Ensure that proper safety and incident reporting procedures are followed. Bring problems to the attention of the Supervisor, Human Resources Manager, or Safety Manager. Must be willing to travel for extended periods of time. May be required to travel independently and have the ability to read and understand road maps. Must be knowledgeable and comply with Federal Motor Carrier regulations. Working around high-pressure water systems and basic pneumatic troubleshooting skills. Types of Equipment We Use: Removal Division - Water Blaster & Grinder Truck Operators on the following: Blasters Inc Equipment Hog Technologies Equipment Cyclone Technologies Equipment MRL Equipment Company, Inc Markings Division - Airmark Applicators, Paint Truck Operators, & Hand Equipment Operators on the following: MRL Equipment Company Inc Paint Trucks Graco Hand Equipment PPG Infrared Heaters K&M International Infrared Heaters Hours of Work: Day, night, and weekend hours will be required Other Duties: Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice. AAP/EEO Statement: Hi-Lite is an EEO Company. It is the policy of Hi-Lite to prohibit discrimination and harassment of any type and to afford EEO to all employees and applicants without regard to race, color, religion, gender, sexual orientation, gender identity, national origin, age, disability, genetic information, marital status, amnesty or status as a covered veteran in accordance with applicable federal, state and local laws. Hi-Lite complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. Hi-Lite's EEO policy applies to all terms and conditions of employment, including hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.
    $15 hourly 22d ago

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