Top 52 Nurse case Jobs in Carolina, Pr

Especialista en Revision Medica
MCS HEALTHCARE HOLDINGS, LLC —San Juan, PR
- Spanish
- Nursing
- RN License
Care Specialist (Nurse Educator) - San Juan, Puerto Rico (National)
IQVIA —San Juan, PR
- $70,000 - $75,000 a year
- Full-time
- Microsoft Word
- Nursing
- RN License
Especialista En Revisión De Utilización Hospitalaria
MCS HEALTHCARE HOLDINGS, LLC —San Juan, PR
- Spanish
- Nursing
- RN License
8d
Especialista De Determinaciones Organizacionales Y Apelaciones
MCS HEALTHCARE HOLDINGS, LLC —San Juan, PR
- Spanish
- Nursing
- RN License
Supervisor(a) Del Programa De Planes De Necesidades Especiales
MCS HEALTHCARE HOLDINGS, LLC —San Juan, PR
- Weekends as needed
- Spanish
- Nursing
- English
5d
Especialista De Calidad Clinica
MCS HEALTHCARE HOLDINGS, LLC —San Juan, PR
- Nursing
- RN License
- Bachelor of Science
Medical Assistant, Research Assistant
Headlands Research —San Juan, PR
- Full-time
- Spanish
- Customer service
- English
- Health savings account
- Paid holidays
Quick Apply
Bilingual Call Center Nurse
Insight Communications —San Juan, PR
- 8 hour shift
- Spanish
- Nursing
- English
Quick Apply
Medical Case Manager
Family Medicine Group —Carolina, PR
- $11 - $14 an hour
- Full-time
- Bilingual
- HIPAA
- Mid-level
Quick Apply
Charge Nurse
San Juan Capestrano —Rio Piedras, PR
- Full-time
- CPR Certification
- Nursing
- Addiction Medicine
14d
HP3 Nurse
APS Health Care PR —Naranjito, PR
- Part-time
- Nursing
- Microsoft Excel
- Microsoft Outlook
Quick Apply
X-Ray Technician
Compass Surgical Partners —Carolina, PR
- Full-time
- Surgery
- BLS Certification
- Mid-level
- Health insurance
- Dental insurance
6d
HD Liaison/First Resp PR (ASEM)
LifeLink Foundation, Inc. —Guaynabo, PR
- Extended hours
- Nursing
- Clean driving record
- Microsoft Excel
- Paid holidays
- Disability insurance
Quick Apply
Doctor
Puerto Rico Case Management Corp. —Guaynabo, PR
- $55 an hour
- Full-time
- HIPAA
- Outpatient experience
- Neurology
- Paid time off
- Flexible schedule
Quick Apply
12d
Staff Psychiatric Mental Health Nurse Practitioner (PMHNP) — Remote | Telehealth | Full-Time or Part-Time | Puerto Rico
Legion Health —Trujillo Alto, PR
- $150,000 - $300,000 a year
- Choose your own hours
- Remote
- Psychiatry
- Mid-level
- Outpatient experience
- Work from home
1d
CRNA - Locum (CT License)
Vivo HealthStaff —San Juan, PR
- $160 - $175 an hour
- 12 hour shift
- Surgery
- BLS Certification
- Mid-level
Quick Apply
Staff RN - ECMO Spec / FT, nights
Children's Nebraska —United States
- Overtime
- Nursing
- RN License
- BLS Certification
- Flexible schedule

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Especialista en Revision Medica

MCS HEALTHCARE HOLDINGS, LLC -
San Juan, PR

Apply Now

Job Details

Qualifications

Nursing
RN License
English
Bachelor of Science in Nursing
Bachelor's degree in nursing
Nursing

Full Job Description

Especialista en Revision Medica

Regular

Exempt

GENERAL DESCRIPTION:

Responsible for conducting clinical reviews of post-service and pre-payment claims requiring medical documentation to determine medical necessity, coding accuracy, reimbursement appropriateness, and compliance with clinical guidelines, payment policies, and regulatory requirements. Applies clinical judgment, critical thinking, and reimbursement knowledge to support accurate claim determinations, cost containment initiatives, and payment integrity.

ESSENTIAL FUNCTIONS:

Conducts clinical reviews and analyses of complex medical records, ancillary services, appeals, and claims requiring clinical documentation to determine medical necessity, coding accuracy, and reimbursement appropriateness, applying clinical judgment and critical thinking in the review of initial determinations and appeals.
Investigates and evaluates claims using applicable systems, clinical guidelines, payment policies, coding rules, and provider agreements to support accurate determination and payment integrity, integrating knowledge of reimbursement to ensure accurate claim outcomes.
Performs clinical and telephonic interventions with providers to validate medical necessity, request additional documentation, discuss clinical scenarios, and support claim determinations, providing guidance and sharing knowledge with providers and internal stakeholders regarding clinical determinations and documentation requirements.
Identifies cost-containment opportunities, inappropriate billing patterns, overpayments, and potential fraud, waste, or abuse situations, escalating cases when applicable, including evaluation of cost drivers such as high-cost diagnostics, transportation, and NCCI-related edits, supporting cost savings initiatives.
Documents case findings, recommendations, rationales, and referral information accurately while maintaining evidence and records according to departmental standards, ensuring documentation meets audit and compliance requirements.
Collaborates with internal departments and participates in meetings, projects, and operational initiatives to support service quality, compliance, and effective claims review operations.
Refers cases to Medical Policy or other appropriate departments when clinical review identifies policy gaps or requires further evaluation.
Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS:

Education and experience: Bachelor's degree in Nursing Sciences. At least two (2) years of clinical nursing experience required. Experience in utilization review, payment integrity, claims review, case management, managed care, or healthcare reimbursement operations preferred. Knowledge of CMS guidelines, coding methodologies, and medical necessity review processes preferred.

Certifications / Licenses: A valid License and Registration of Nurse & Association Nursing Professionals of Puerto Rico are required.

Other: Extensive knowledge of medical terminology and experience in ICD-10 and CPT coding is preferred.

Languages:
Spanish – Intermediate (comprehensive, writing and verbal)
English – Intermediate (comprehensive, writing and verbal)

“We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.”

Apply Now

Refine Your Search

nurse case jobs in carolina, pr

Especialista en Revision Medica

Care Specialist (Nurse Educator) - San Juan, Puerto Rico (National)

Especialista En Revisión De Utilización Hospitalaria

Especialista De Determinaciones Organizacionales Y Apelaciones

Supervisor(a) Del Programa De Planes De Necesidades Especiales

Especialista De Calidad Clinica

Medical Assistant, Research Assistant

Bilingual Call Center Nurse

Medical Case Manager

Charge Nurse

HP3 Nurse

X-Ray Technician

HD Liaison/First Resp PR (ASEM)

Doctor

Staff Psychiatric Mental Health Nurse Practitioner (PMHNP) — Remote | Telehealth | Full-Time or Part-Time | Puerto Rico

CRNA - Locum (CT License)

Staff RN - ECMO Spec / FT, nights

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