San Juan, San Juan, Puerto Rico

Medical Policy and Operational Payment Rules Manager/Coding

 Job Description:

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Our partner, a committed to excellence prominent local insurance company, as they eagerly search for a proactive and ambitious individual to step into the role as a Medical Policy and Operational Payment Rules Manager/Coding. This exciting opportunity involves directing the entire process of payment rules definition, medical policy development, adoption, definition, and communication. If you're enthusiastic about taking on a challenging and rewarding role, this position offers a unique platform to make a significant impact in the insurance industry.


  • Ensures the timely and accurate analysis and update of standard code sets, associated fees, and payment rules.
  • Conducts periodic reviews of complaints and grievances, making recommendations and implementing changes in policies, operational processes, or systems.
  • Audits system updates to guarantee the proper functioning of configured rules and policies.
  • Identifies opportunities for implementing payment rules that align with appropriate clinical utilization of covered services.
  • Supports payment integrity initiatives and projects to ensure the correct application of established medical policies and payment rules.
  • Evaluates, reports, and oversees the utilization and financial impact of medical policies and payment rules.
  • Establishes a formal structure to keep internal and external clients informed about medical policies and payment rules.
  • Organizes and prepares presentations and agendas for meetings, including those of the Providers Advisory Committee (PAC) and corporate meetings.
  • Ensures the proper utilization of payment rules in accordance with regulatory guidelines by line of business.
  • Collaborates with the medical team to discuss policies that require consensus on clinical input.
  • Attends calls and Ad-Hoc meetings for the Application Managed Services (AMS).
  • Evaluates claims denials and rejection reports to determine the root cause of issues and develops corresponding action plans.
  • Approves and provides detailed documentation for change requests to any medical policy management contractors, as applicable.
  • Performs administrative tasks, including preparing and controlling the departmental budget, planning and development, and managing performance.


  • Bachelors degree in Business Administration, Health Information Management, or health related Science (Masters preferable).
  • Five (5) to seven (7) years of experience in related fields, including medical coding and/or billing.
  • Preferably with a professional certification in medical coding.
  • Experience in supervisory functions.
  Required Skills:

Adoption Grievances Offers Search ROOT Reviews Insurance Contractors Presentations Administration Documentation Planning Business Communication Science Management