Top 222 Regulatory specialist Jobs in Puerto Rico

Grievance & Appeals Specialist Grievance & Appeals Specialist
TeleMedik a Firstsource Company —Puerto Rico
- $16 - $17 an hour
- Weekends as needed
- Remote
- Microsoft Excel
- Microsoft Outlook
- HIPAA
- Health savings account
- Health insurance
Quick Apply
9d
Specialist QA
Kelly Services —Juncos, PR
- $38 an hour
- Full-time
- Spanish
- Computer science
- Computer Science
- Paid holidays
- Disability insurance
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Regulatory QA Specialist
HR Works —Barceloneta, PR
- $30 - $45 an hour
- Contract
- Senior level
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Clinical Research Regulatory Specialist
Total Outcomes Partners, LLC —San Juan, PR
- $30 an hour
- Contract
- Hybrid work
- Spanish
- English
- Bachelor's degree
- Flexible schedule
Quick Apply
13d
QA / Documentation Specialist
Qualitech Management Solutions —Barceloneta, PR
- $20 - $40 an hour
- Part-time
- Background check
- Mid-level
- Bachelor's degree
Quick Apply
JR Validation Specialist (Entry Level)
Validation & Engineering Group —San Juan, PR
- Entry level
Quick Apply
Quality - Document Control Specialist
Viant Medical —Vega Baja, PR
- Full-time
- Customer service
- Writing skills
- Mid-level
Quick Apply
9d
Specialist QA
BioPharma Consulting JAD Group —Juncos, PR
- Contract
- Spanish
- Doctoral degree
- Computer Science
Quick Apply
13d
Complaints & Grievance Specialist
Alivia Health —Guaynabo, PR
- Full-time
- HIPAA
- Mid-level
- Continuous improvement
Quick Apply
EHS SPECIALIST
MENTOR TECHNICAL GROUP CORP —Dorado, PR
- Engineering
- Mid-level
- Ability to lift 50 pounds
Quick Apply
COMPLIANCE SPECIALIST
MENTOR TECHNICAL GROUP CORP —Caguas, PR
- Mid-level
- 3 years
- Analysis skills
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Quality Assurance (QA) Specialist II
Artech LLC —Barceloneta, PR
- $20.00 - $21.16 an hour
- Contract
- Bilingual
- Mid-level
- Manufacturing
Quick Apply
Photo Specialist
Walgreens —Municipio de Isabela, PR
- $15.00 - $17.50 an hour
- Weekends as needed
- English
- Fair chance
- Entry level
Medical Data Entry Specialist
PanOncology Trials —San Juan, PR
- Full-time
- Spanish
- English
- Administrative experience
- Health insurance
- Dental insurance
Quick Apply
12d
SENIOR PROJECT MANAGER (PE Professional Engineer License Required)
Custom Group, LLC. PR —Guaynabo, PR
- $85,000 - $92,000 a year
- Full-time
- Spanish
- Schematics
- Construction site
- Health insurance
- Paid time off
Quick Apply
INVESTMENT CLIENT EXPERIENCE SPECIALIST
TPIS —Bayamón, PR
- $16 - $20 an hour
- Full-time
- Spanish
- Microsoft Excel
- Microsoft Outlook
Quick Apply
Sealing Validation Specialist II - 60715 (Añasco)
One Group —Añasco, PR
- Extended hours
- Background check
- Spanish
- Microsoft Excel
Quick Apply
INVESTMENT CLIENT EXPERIENCE SPECIALIST
TPIS —San Juan, PR
- $16 - $20 an hour
- Full-time
- Spanish
- Microsoft Excel
- Microsoft Outlook
Quick Apply
Sr. Engineer
PRPDG —Juncos, PR
- $45 - $50 an hour
- Full-time
- Spanish
- Doctoral degree
- 5 years
Quick Apply
Validation Specialist III - 60702 (Añasco)
One Group —Añasco, PR
- Extended hours
- Background check
- Spanish
- 6 years
Quick Apply

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Grievance & Appeals Specialist Grievance & Appeals Specialist

TeleMedik a Firstsource Company
Puerto Rico

Quick Apply

Job Details

Full-time
$16 - $17 an hour
9 days ago

Benefits

Health savings account
Health insurance
Dental insurance
401(k)
Flexible spending account
Paid time off
Work from home
Vision insurance
Flexible schedule
Life insurance

Qualifications

Appeals
Microsoft Excel
Microsoft Outlook
Workflow management (operations management method)
HIPAA
Medical claims processing software
Administrative experience
High school diploma or GED
Medical insurance appeals management
Health information management
Insurance claims appeal handling
Medical terminology

Full Job Description

Job Overview

We are seeking a highly organized and detail-oriented Claims & Appeals & Grievances (A&G) Specialist to join our Healthcare Operations team. The ideal candidate will have a minimum of two years of experience supporting US healthcare back-office operations with expertise in claims processing, appeals, grievances, and administrative support functions.

This role is responsible for reviewing and processing healthcare claims, researching and resolving claim-related issues, coordinating appeals and grievance activities, ensuring compliance with regulatory requirements, and maintaining accurate documentation. The successful candidate will demonstrate strong analytical skills, attention to detail, and the ability to work efficiently in a fast-paced, quality-driven environment.

Key Responsibilities

Claims Operations

Review, validate, and process medical, behavioral health, and pharmacy claims in accordance with health plan policies and established business rules.
Perform claim research to identify discrepancies, missing information, eligibility concerns, authorization requirements, and benefit coverage issues.
Verify member eligibility, provider information, coding accuracy, and supporting documentation prior to claim adjudication or escalation.
Analyze suspended, pending, denied, or rejected claims and determine appropriate next steps.
Ensure claims are processed accurately within established turnaround times and service level agreements (SLAs).
Document all actions, findings, and resolutions within the claims management system.

Appeals & Grievances

Receive, review, and process member and provider appeals and grievances in accordance with CMS, state, federal, and organizational requirements.
Research claim history, medical records, benefit plans, provider contracts, and supporting documentation to determine appropriate case resolution.
Coordinate with internal clinical, compliance, provider services, customer service, and operations teams to obtain additional information when required.
Prepare case summaries, correspondence, and resolution documentation while ensuring completeness and accuracy.
Track appeal and grievance cases from receipt through final resolution while meeting regulatory turnaround time requirements.
Escalate complex or high-risk cases to appropriate departments as necessary.

Compliance & Quality

Adhere to CMS, HIPAA, NCQA, and internal compliance standards.
Ensure all documentation is complete, accurate, and audit-ready.
Meet departmental productivity, quality, accuracy, and turnaround time metrics.
Participate in required compliance, privacy, and operational training programs.
Maintain current knowledge of healthcare regulations, benefit plans, and organizational policies.

Back Office Operations

Perform data entry, record maintenance, document indexing, and quality validation activities.
Maintain confidentiality of Protected Health Information (PHI) in accordance with HIPAA regulations.
Review operational reports and work queues to prioritize daily workload.
Identify processing errors, trends, or recurring issues and recommend corrective actions.
Participate in quality audits, process reviews, and continuous improvement initiatives.
Support cross-functional operational projects and departmental objectives.

Qualifications

High School Diploma or GED required; Associate's or Bachelor's degree preferred.
Minimum of 2 years of experience in US Healthcare Back Office Operations.
Experience in healthcare claims processing and Appeals & Grievances.
Knowledge of commercial, Medicare, and/or Medicaid health plans.
Understanding of medical terminology, healthcare benefits, and claim workflows.
Familiarity with CPT, ICD-10-CM, HCPCS, and healthcare documentation.
Experience working with claims processing systems, workflow management tools, and electronic document management systems.
Proficiency with Microsoft Office, including Excel, Word, and Outlook.
Strong written and verbal communication skills.
Excellent analytical, organizational, and problem-solving abilities.

Preferred Qualifications

Experience in Managed Care, Health Insurance, Third-Party Administration (TPA), or Healthcare Business Process Outsourcing (BPO).
Knowledge of healthcare regulations governing appeals and grievance processes.
Experience handling high-volume production environments.
Familiarity with quality assurance processes and operational audits.

Skills & Competencies

Claims Processing
Appeals & Grievance Administration
Claims Investigation
Healthcare Documentation Review
Data Validation & Quality Assurance
Regulatory Compliance

Working Environment This role may involve working with secure and confidential data, requiring adherence to strict data security and privacy standards. Some after-hours or weekend availability may be required during system maintenance, and month end operations.

We are an Equal Opportunity Employer. All qualified applicants are considered for employment without regard to race, color, age, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by federal, state or local law.

Pay: $16.00 - $17.00 per hour

Benefits:

401(k)
Dental insurance
Flexible schedule
Flexible spending account
Health insurance
Health savings account
Life insurance
Paid time off
Vision insurance
Work from home

Application Question(s):

Do you have experience working with claims processing systems, workflow management tools, and electronic document management systems?
Are you familiarity with CPT, ICD-10-CM, HCPCS, and healthcare documentation?
Do you have Knowledge of commercial, Medicare, and/or Medicaid health plans?

Education:

High school or equivalent (Required)

Experience:

US Healthcare Back Office Operations: 2 years (Required)

Work Location: Remote

Quick Apply

Refine Your Search

regulatory specialist jobs in puerto rico

Grievance & Appeals Specialist Grievance & Appeals Specialist

Specialist QA

Regulatory QA Specialist

Clinical Research Regulatory Specialist

QA / Documentation Specialist

JR Validation Specialist (Entry Level)

Quality - Document Control Specialist

Specialist QA

Complaints & Grievance Specialist

EHS SPECIALIST

COMPLIANCE SPECIALIST

Quality Assurance (QA) Specialist II

Photo Specialist

Medical Data Entry Specialist

SENIOR PROJECT MANAGER (PE Professional Engineer License Required)

INVESTMENT CLIENT EXPERIENCE SPECIALIST

Sealing Validation Specialist II - 60715 (Añasco)

INVESTMENT CLIENT EXPERIENCE SPECIALIST

Sr. Engineer

Validation Specialist III - 60702 (Añasco)

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