Providers Operations Management Specialist

Regular
Exempt

GENERAL DESCRIPTION:
Assists in investigating cases for resolution in compliance with the applicable regulations, guidelines, and contractual agreements. Participates in the implementation processes of the special networks, prompt payment, and directory complaints, which entails analyzing the operational impact, validations, and implementation of actions to maintain compliance with the directories in all their formats. Responsible for assessing, developing, and establishing an action plan for the identified points in any of these areas to ensure corporate processes.
ESSENTIAL FUNCTIONS:

- Provides support within the unit regarding timely resolutions of grievances and appeals filed by Addiuva according to the corresponding line of business.
- Participates in the design and development of success indicators, operational metrics, and process flow analysis of the initiatives in their charge.
- Conducts quality calls for Service, Credentialing, and Contracting units and reports findings to management for appropriate action.



Develops reports on quality calls made to Service, Credentialing, and Contracting units to obtain metrics that lead to service satisfaction and complaint-handling evaluation.
- Develops progress reports, analyzes data, and provides follow-up for the appropriate actions.
- Creates files of the various monitoring efforts and submits them to the appropriate units as required.
- Receives, analyzes, and seeks solutions to service issues from members and contracted providers, as applicable.
- Refers, directs, and monitors configuration requests from providers, as applicable. This includes documentation in automated systems and/or other designated systems.
- Maintains effective communication with the operational owners of each area, providers, and business partners on issues related to contractual agreements with the company.
- Supports management in meetings with the company operational owners, providers, a

📌 Providers Operations Management Specialist (San Juan)
🏢 MCS Healthcare Holdings, LLC (MCS)
📍 San Juan