Process Specialist - RN

Process Specialist -RN Clinician- Aguadilla, Puerto Rico
​(Puerto Rico Registered Nurse with Florida Endorsement Required)

In this role, you will be responsible for accurate and timely processing of Healthcare claim service request and processing of claims using your medical knowledge to process according to a workflow that requires the review and evaluation of the service request as per SOP.

For this role, you must be familiar with Medical Policy, Familiar with Clinical service requests, correspondence inquiries and image reviews and MUST have the Florida endorsement. 

Location for this position is Aguadilla, Puerto Rico

Qualifications
Basic

• High School Diploma or GED Equivalent
• At least 2 years of experience relating to the job description

Preferred

1. Registered Nurse in Puerto Rico with a valid Florida endorsement
2. Fully Bilingual- English and Spanish- (All work performed will be in English) 
3. Intermediate to advanced knowledge in using MS Office and ability to learn and use various computer software.
4. Past experience in an office/clerical setting in the medical field
5. Experience in any claim adjudication platform
6. Certification in medical coding (CPT, ICD-10
7. ​Exposure to Healthcare Claims products (Indemnity, PPO, POS/DA, EPO, HMO)
8. Prefer knowledge of Workman's Compensation, Medicare, COB, no fault.
9. Prior claims experience in medical coding, case management, cost containment review, medical claim management will be preferred
10. Exposure to anti-fraud initiatives in clinical area
11. Awareness of clinical practice guidelines used by health plans to develop medical policy
12. Possess eye for details
13. Knowledge of Microsoft Office Products.
14. Team Player, Analytical, Written and Verbal Communication Skills, Interpersonal Skills and Positive Attitude

Job responsibilities: 
Some of the responsibilities that our Clinicians handle include, but are not limited to:
 

• Responsible for accurate and timely processing of Healthcare claim service request and processing claims

• Reviews, evaluates the service request as per SOP

• Familiar with Medical Policy, Familiar with Clinical service requests, correspondence inquiries and image review

• Forward the cases to appropriate teams, post the in-scope activities have been completed as per SOP

• Prep medical records for clinical review

• End to end processing and resolution of clinical claims and correspondence

• Understand/interpret medical terminology including clinical notes and reports

• Able to review medical policies and determine the appropriate claim processing or clinical review process decisions (pay, request additional records, refer for clinical review)

• Review and determine pricing for clinical claims in accordance with negotiated pricing agreements

• Adept knowledge of verifying member benefits, eligibility verification and medical necessity determination

• To apply clinical judgement in lines of applicable guidelines while they provide post service Medical Necessity Determination (MND) reviews for Claim Policy business area led by reputed US Payer organization/s.

• To work in collaboration with Medical Directors to deliver top quality medical necessity determination services to clients.

Note: Applicants for employment in the U.S. must possess work authorization which does not require sponsorship by the employer for a visa (H1B or otherwise).

The job entails sitting as well as working at a computer for extended periods. Should be able to communicate by telephone, email or face to face.

About Us

Infosys BPM, the business process management subsidiary of Infosys (NYSE: INFY), provides end-to-end transformative services for its clients across the globe. The company has integrated IT and BPM solutions approach enables it to unlock business value across industries and service lines, and address business challenges for its clients. Utilizing innovative business excellence frameworks, ongoing productivity improvements, process reengineering, automation, and cutting-edge technology platforms, Infosys BPM enables its clients to achieve their cost reduction objectives, improve process efficiencies, enhance effectiveness, and deliver superior customer experience.   Infosys BPM has 32 delivery centers in 14 countries spread across six continents, with 35,058 employees from over 80 nationalities, as of March 2018.  

The company has been consistently ranked among the leading BPM companies globally and has received over 60 awards and recognitions in the last 5 years, from key industry bodies and associations like the Outsourcing Center, SSON, and GSA, among others. Infosys BPM also has very robust people practices, as substantiated by the various HR-specific awards it has won over the years. The company has consistently been ranked among the top employers of choice, based on its industry leading HR best practices. The company’s senior leaders contribute widely to industry forums as BPM strategists. 
 
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