Job details

Country

USA

State / Region / Province

Puerto Rico

Work Location

Aguadilla, PR

Domain

Operations

Interest Group

IBPO Puerto Rico

Company

IBPO USA

Requisition ID

116501BR

Job description

Job Title: Registered Nurse
Location: Aguadilla, Puerto Rico
​(Must have Puerto Rico Registered Nurse License with the Florida or Any US state 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.



Job responsibilities:

Responsible for accurate and timely processing of healthcare claim service request and processing claimsReviews, evaluates the service request as per SOPFamiliar with Medical Policy, Familiar with Clinical service requests, correspondence inquiries and image reviewForward the cases to appropriate teams, post the in-scope activities have been completed as per SOP (Standard operating Procedure)Prep medical records for clinical reviewEnd to end processing and resolution of clinical claims and correspondenceUnderstand/interpret medical terminology including clinical notes and reportsAble 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 agreementsAdept knowledge of verifying member benefits, eligibility verification and medical necessity determinationTo 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/sTo work in collaboration with Medical Directors to deliver top quality medical necessity determination services to clientsBasic QualificationsHigh School Diploma or GED EquivalentAt least 2 years of experience relating to the job descriptionPreferred QualificationsFully Bilingual- English and Spanish- (All work performed will be in English) Current Puerto Rico Registered Nurse valid license and a valid Florida or any US state endorsementIntermediate to advanced knowledge in using MS Office and ability to learn and use various computer softwarePast experience in an office/clerical setting in the medical fieldExperience in any claim adjudication platformCertification in medical coding (CPT, ICD-10Exposure to Healthcare Claims products (Indemnity, PPO, POS/DA, EPO, HMO)Prefer knowledge of Workman's Compensation, Medicare, COB, no faultPrior claims experience in medical coding, case management, cost containment review, medical claim management will be preferredExposure to anti-fraud initiatives in clinical areaAwareness of clinical practice guidelines used by health plans to develop medical policyPossess eye for detailsKnowledge of Microsoft Office ProductsTeam Player, Analytical, Written and Verbal Communication Skills, Interpersonal Skills and Positive Attitude

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 of time. Should be able to communicate by telephone, email or face to face.

Work Model:
This role is onsite 5 days per week in the office in Aguadilla.

Who We Are
Infosys BPM Limited, a wholly owned subsidiary of Infosys Limited (NYSE: INFY), provides end-to-end transformative business process management (BPM) services for its clients across the globe. The company’s 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 45 delivery centers in 16 countries spread across 5 continents, with 56,541 employees from 107 nationalities, as of December, 2023.

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, on the basis of its industry leading HR best practices. The company’s senior leaders contribute widely to industry forums as BPM strategists.

EOE/Minority/Female/Veteran/Disabled/Sexual Orientation/Gender Identity/National Origin

Infosys BPM is an equal opportunity employer and all qualified applicants will receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, spouse of protected veteran, or disability.