Claims Analyst III

Regular
Non-Exempt

GENERAL DESCRIPTION:
Analyzes, processes, and adjudicates all types of complex claims submitted in Centers for Medicare and Medicaid Services Form 1500 (CMS‑1500) and Uniform Billing Form 04 (UB‑04) formats, applying the highest level of analytical judgment to determine appropriate payment or denial. This includes the evaluation of adjustments, member reimbursements, grievances, reconciliations, Coordination of Benefits (COB), United States claims, non‑participating provider claims, recoveries, reinsurance, life insurance claims, and other specialized transactions. Requests additional information, when necessary, in accordance with applicable benefits and policy requirements, and within the maximum adjudication authority limit established by current policy and procedure.
ESSENTIAL FUNCTIONS:
•Processes complex claims, including adjustments, COB, samplings, United States claims, non‑participating provider claims, grievances, member reimbursements, multiple categories of adjustments, reconciliations, recoveries, reinsurance,



and life insurance claims, among other specialized transactions.
•Evaluates and resolves claims referred from prior authorization levels and determines when analyzed claims require additional support, coordination, or intervention from other departments.
•Refers claims and/or adjustments to the necessary departments to obtain additional information, support outreach efforts, or secure the required approvals for payment adjudication or denial decisions.
•Reports any evidence of unusual utilization patterns, suspected attempted fraud, or irregular claim activity detected during the adjudication process to the appropriate department and immediate supervisor.
•Reports to the immediate supervisor any evidence of deficiencies in system configuration, contract coverage setup, or provider agreement discrepancies identified during claim adjudication.
•Reports any identified errors in payment or denial patterns to the

📌 Claims Analyst III (San Juan)
🏢 MCS Healthcare Holdings, LLC (MCS)
📍 San Juan