Grievances & Appeals Specialist

Regular
Exempt

GENERAL DESCRIPTION:
Analyzes, investigates, supports, and answers Grievances, Dental Pre-Service, and Payment Appeals filed by members, insureds, Providers, and/or Non-Part Providers within the time stipulated contractually for both Lines of Business (LOB)and following the terms stated in the contracts established and the rights of Patients and Providers.
ESSENTIAL FUNCTIONS:
• Analyzes, investigates, resolves, and responds to Grievances, Dental Pre-Service, and Payment Appeals,filed by MCS Classicare or MCS Life policyholders, in compliance with Centers for Medicare and Medicaid Services (CMS)regulation, Office of the Commissioner of Insurance (OIC), and internal policies.
• Consults and collaborates with other Departments or Units, Dental Physician reviewers, Delegated Entities, and/or suppliers as part of the analysis, investigation, and support process; validates their responses, assesses root causes, identifies areas of opportunity, and ensures proper collaboration and documentation based on the impacted issue.




• Documents cases and uses the Grievances & Appeals management platform to support analysis and complete the resolution of the case. When required, send notifications to Net Claim system to complete the resolution of dental pre-service appeals.
• Case reconsiderations or member requests must be handled as established by the applicable regulation and due process to CMS contracted Independent Review Entities (IRE - Maximus). Case files must be documented in English during the appeals process, considering the required documentation and timeliness. This process impacts directly, two (2) Stars metrics related to Appeals Timeliness and Appeals Review (Upheld).
• For appeals, in the event a reconsideration or member request is denied and request second level appeal, for MCS Life LOB, complies with the Office of the Commissioner of Insurance (OIC) regulation and submits cases to Independent Review Organizations (

📌 Grievances & Appeals Specialist (San Juan)
🏢 MCS Healthcare Holdings, LLC (MCS)
📍 San Juan