Role: RN Clinician
Location: Aguadilla PR (Onsite)
Shift: 8am – 5pm, Mon- Fri, no weekends or evenings
Must have Puerto Rico Registered Nurse License with the Florida or Any US state Endorsement Required
Job Description:
The job description is for a
Process Specialist - RN Clinician
role located in Aguadilla, Puerto Rico. This role requires a
Puerto Rico Registered Nurse (RN) with a valid Florida or any US state endorsement
. The primary responsibilities involve the accurate and timely processing of healthcare claim service requests, utilizing medical knowledge to evaluate and process claims according to specific workflows and Standard Operating Procedures (SOPs).
Key Responsibilities:
Processing Healthcare Claims
: Review, evaluate, and process healthcare claim service requests as per SOPs.
Medical Policy and Clinical Knowledge
: Familiarity with medical policy, clinical service requests, and medical terminology to make decisions regarding claim processing.
Collaboration and Communication
: Work with other teams, including forwarding cases after completing necessary steps, and collaborating with Medical Directors for medical necessity determinations.
Claims Review
: Analyze clinical claims, determine pricing according to agreements, and apply clinical judgment to assess medical necessity.
Documentation and Reporting
: Prep medical records for review, handle correspondence inquiries, and resolve clinical claims.
Basic Qualifications:
Education
: High School Diploma or GED.
Experience
: At least 2 years related to the job description.
Preferred Qualifications:
Licensing
: Registered Nurse in Puerto Rico with a Florida or any US state endorsement.
Language Skills
: Fully bilingual in English and Spanish.
Technical Skills
: Proficiency in MS Office and other software tools.
Experience
: Previous experience in office settings within the medical field, claim adjudication platforms, and possibly in medical coding, case management, or cost containment reviews.
Job Types: Full-time, Contract
Pay: $21.00 per hour
Expected hours: 40 per week
Benefits:
Flexible schedule
Health insurance
Life insurance
Paid sick time
Paid time off
Medical Specialty:
Critical & Intensive Care
Emergency Medicine
Medical-Surgical
Primary Care
Public Health
Surgery
Work Location: In person
