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
ESSENTIAL FUNCTIONS
- Analyzes, reconciles, and processes transactions at the insured's subscription level, such as additions, terminations and maintenance that include, but are not limited to, demographic changes, changes in coverage and indicators.
- Applies subscription rules and established procedures to subscription requests received.
- Reviews the transactions processed to ensure the accuracy of the information configured according to the requests received.
- Analyzes error reports resulting from the eligibility processes and corrects entries to the system in accordance with the request by affiliate.
- Performs maintenance associated with the Coordination of Benefits process (COB), Medicare as a secondary payer (MSP) and third-party liability insurance (TPL) applying the established rules.
- Analyzes reports and, if necessary, corrects the activation of policyholders in the PBM systems.
- Evaluates and determines the action to be taken on requests from the insured, in accordance with applicable regulations.
- Comply with the established and metric indicators (MTM, internal, external and compliance). Inform to management any situation that may affect compliance or impact execution.
- Reconciles, identify, documents, and submits retroactive eligibility transactions through Reeds and Associates, processor designated by CMS.
- Reconciles, identifies, analyzes, and corrects eligibility or discrepancies in eligibility, demographic data and indicators that affect the eligibility of the insured with the services of the delegated entities, CMS and ASES premium.
- Reconciles, identifies, analyzes, and corrects late registration penalty discrepancies between CMS and the subscription system.
- Receives, evaluates, and responds to the decisions of Maximus Federal Services and performs the corresponding transactions in the subscription system.
- Other tasks as assigned by the Management and that are essential.
EDUCATION
- Associate's Degree in Business Administration
EXPERIENCE
Associate Degree (60-64 college credits) in Business Administration, preferable, with one (1) to three (3) years of related experience, preferably with health insurance industry. Or three (3) to five (5) years work experience in lieu of.
LICENSES AND CERTIFICATIONS
- None required
COMPETENCIES
- Manages Ambiguity
- Instills Trust
- Collaborates
- Customer Delight
- Action Oriented
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.