Job Description

Performs a variety of tasks for the Service Authorizations Unit of the Department of Health Services. The Service Authorization Nurse is responsible for ensuring that members receive the optimal level of benefit coverage for services requiring coordination. Oversees the quality and proper utilization of services. Acts as the primary liaison between enrolled beneficiaries and providers to manage the service request process that requires coordination.

Essential Functions:

• Handles requests for pre-authorization service coordination.
• Reviews, evaluates, and ensures that requests are complete.
• Meets productivity metrics, quality standards, and applicable regulatory processes.
• Documents transactions in the system.
• Makes calls to members and providers to obtain necessary clinical information to process the request.
• Identifies benefit limitations/exclusions for the authorization process.
• Reviews medical information using criteria, protocols, and/or guidelines for the authorization process.
• Conducts the authorization process based on eligibility criteria and benefit coverage.
• Ensures confidentiality and compliance with all applicable state and federal regulations for Health Call Centers, including HIPAA and internal policies for handling confidential information.
• Promotes quality and service excellence in all management processes.
• Completes core and functional training, as well as all procedures established by regulatory agencies, contractual requirements, and applicable certification standards (including but not limited to URAC).
• Performs other related tasks.

Requirements:

• Bachelor's degree in Nursing with clinical experience.
• Required Credentials: Active nursing license to practice in Puerto Rico, registration, and professional affiliation.
• Advanced knowledge of computer applications and/or Microsoft Office.
• Service-oriented mindset and commitment to customer service.
• Excellent bilingual verbal and written communication skills (Spanish and English).
• Ability to prioritize tasks.
• Strong teamwork skills.
• Fast documentation and internet navigation skills.
• Availability for rotating shifts (including weekends/holidays), Monday to Saturday from 8:00 AM to 6:00 PM.

What Are the Benefits of Joining Our Team?

• In-service training on regulatory and health-related aspects.
• 24/7 telemedicine service.
• Free employee health and wellness programs.
• Opportunities for growth and development.
• Contributing to the health and well-being of the population.

Job Type: Full-time

Contract Type: Professional Services, Fixed-term (6 months), with automatic month-to-month renewal after the initial 6-month period.

Work Location: On-site job in Guaynabo, PR

EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER (EEOC)