Claims Representative

Job Title: Claims/Network Management RepLocation: San Juan, PR 00918Duration: 12 MonthsAnticipated Start Date: ASAP(Please note this is the target date and is subject to change. BCforward will send official notice ahead of a confirmed start date.)Job Type: ContractPay Range: $14-$15/hr(Please note that actual compensation may vary within this range due to factors such as location, experience, and job responsibilities, and does not encompass additional non-standard compensation (e.g., benefits, paid time off, per diem, etc.).
Work Schedule:Monday through Friday from 8:00 am to 5:00 pm.3-4 times per week in office.
Job Description:Provides comprehensive services to the provider community through researching more complex provider issues. Primary duties may include, but are not limited to: Serves as point of contact for other internal departments regarding provider issues that may impact provider satisfaction. Researches and resolves the complex provider issues and appeals for prompt resolution. Coordinates prompt claims resolution through direct contact with providers and claims department. May perform periodic provider on-site visits. Provides assistance with policy interpretation. Researches, analyzes and recommends resolution of provider disputes, issues with billing, and other practices. Assists providers with provider demographic changes as appropriate. Responds to provider issues related to billing, pricing, policy, systems and reimbursements. Identifies and reports on provider utilization patterns which have a direct impact on the quality of service delivery. Determines if providers were paid according to contracted terms. Requires a H.S. diploma or equivalent and a minimum of 3 years of customer service experience; or any combination of education and experience, which would provide an equivalent background. Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills strongly preferred.
Systems & Operational SkillsPrior experience using a case management/CRM tool—Salesforce experience strongly preferred (case creation, queue routing, updating status, notes, and attachments).Prior experience with an enterprise content management platform—OnBase experience strongly preferred (uploading, indexing, metadata tagging, and retrieval).Strong data entry accuracy and attention to detail (ability to catch missing/incorrect information before submission).Strong document handling discipline (version control, naming conventions, correct attachment to the right case, clean audit trail).
Analytical / Process SkillsAbility to follow detailed SOPs/work instructions and make consistent decisions using checklists.Ability to analyze transactions to confirm completeness, required documentation, and correct approval path.Ability to identify issues and escalate appropriately (exceptions, missing approvals, policy deviations).
Compliance & Risk MindsetDemonstrated ability to handle sensitive information and follow controls related to HIPAA (privacy/security of PHI) and SOX (documentation integrity, traceability, audit readiness).High accountability for accuracy, documentation quality, and timeliness.
Communication/TeamingClear written communication for case notes and requests for missing information.Ability to work in a high-volume, deadline-driven environment.
Preferred Qualifications (Nice-to-have)Bilingual (English/Spanish) preferred (not required), especially for written follow-ups and clarifications.Experience in contracting operations, provider contracting, procurement, legal operations, or other regulated back-office environments.Intermediate Excel skills (filters, pivot tables, basic data validation) for tracking and reconciliation.Experience working with SLA-based queues and productivity targets.
Key Competencies (Behavioral)Detail orientation and consistency (“do it right the first time”).Strong organization and prioritization across multiple cases.Reliability and ability to ramp quickly with minimal supervision.Professional judgment and discretion with confidential data.