At Triple-S, we are committed to providing meaningful job experiences for Valuable People (Gente Valiosa). We strive for excellence in everything we do, from the way we work together to the way we serve our customers.
When you join Triple-S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses.
Let's build healthier communities together, join now!
JOB SUMMARY
Responsible for performing independent audits of Configuration Management processes, controls, and configuration-related claims outcomes to assess compliance, control effectiveness, and adherence to established requirements. This role evaluates configuration processes and claims impacted by configuration, identifies control gaps and recurring issues, monitors corrective actions, and maintains audit evidence to provide independent assurance that Configuration Management activities support accurate claims outcomes, regulatory compliance, and effective operational controls.
ESSENTIAL FUNCTIONS
- Perform independent Configuration Management audits to assess compliance with established processes, standards, controls, and requirements.
- Audit claims impacted by configuration to evaluate claims accuracy and identify potential configuration-related errors, trends, or control weaknesses.
- Assess Configuration Management activities for compliance with applicable laws, regulations, policies, and internal requirements.
- Review adherence to established SOPs, configuration standards, procedures, and control requirements across applicable Configuration Management functions.
- Perform control effectiveness testing to determine whether established configuration controls are appropriately designed, consistently executed, and achieving their intended objectives.
- Analyze audit findings and configuration-related issues to identify root causes, recurring patterns, systemic risks, and control gaps.
- Develop, document, and communicate audit findings, observations, risks, and recommendations based on supporting evidence and established audit criteria.
- Monitor Corrective Action Plans (CAPs) resulting from audit findings and verify timely completion and effectiveness of corrective actions.
- Support internal and external audits, including coordination of requested documentation, configuration evidence, responses, and follow-up activities.
- Perform independent evaluations of Configuration Management processes and operational performance to identify opportunities to strengthen controls, compliance, accuracy, and consistency.
- Monitor Configuration Management KPIs, quality indicators, audit results, and supporting evidence to identify trends and areas requiring additional review.
- Audit applicable MRDT configuration to assess accuracy, compliance, documentation, and adherence to established configuration requirements.
- Review code readiness implementations and claims core-system updates associated with CMS, AMA, Optum Coding, BCBS, and other applicable requirements to assess implementation compliance and control effectiveness.
- Collaborate with Configuration Quality Assurance, Benefit Configuration, Provider Configuration, Claims, Compliance, Payment Integrity, and other applicable stakeholders to research audit findings and support corrective actions.
- Maintain complete, accurate, and traceable audit documentation and evidence, and escalate significant findings, recurring deficiencies, compliance risks, or potential claims impacts to Configuration Quality Assurance leadership.
EDUCATION
- Bachelor's Degree in Science or Computer Science
EXPERIENCE
- Bachelor’s Degree (BD) in Science, Computer Science or Technical Degree, Arts or Business Administration, preferable.
- Minimum of two (2) years of experience in applicable core system platform as an end-user.
- Minimum of two (2) years of experience in operational area of health insurance plan.
- Minimum of one (1) year of configuration experience in Claims Core System.
LICENSES AND CERTIFICATIONS
- None required
COMPETENCIES
- Action Oriented
- Collaborates
- Customer Delight (Employee)
- Instills Trust
- Manages Ambiguity
It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, sex, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company.
Equality Employment Opportunity/Affirmative Action for People with Disabilities/Veterans. Employer with E-Verify to verify the eligibility of employment of all the new employees.
We encourage Veterans and Disabled to Apply.