Provider Performance Consultant - TSS

Provider Performance Consultant

Guaynabo, PR

About Us

At Triple S, we are committed to provide meaningful job experiences for Valuable People (Gente Valiosa). We encourage an environment of high ethical standards, always excelling in service, collaboration among the company, agility to deliver timely, and embracing accountability for results.

When you join Triple S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses.

Let's build healthier communities together, join now!

About The Role

Leads tasks working with other analyst's accurate and complete capitation and incentives analysis and reconciliation process, monitor capitation arrangements, and all type of incentives in accordance with the contracts and calendar. Research and analyze financial information data to help management make well informed decisions, write reports and monitor financial and performance movement. Understand business operations for the success, providing internal customers with relevant reports and insights to support their growth. Gives support so that the tasks are completed on time and maintain an organized plan of the same. Serves as a liaison and participate in the planning, management and administration of internal and external projects to the Division.

What You'll Do

Serves as the Medical group and provider point of contact as it relates to financial reconciliation review, adjudications, and cost reporting.

• Ensure that capitation payments are correct and in accordance with IPAs Contract.
• Performs analytical procedures for Premium and Claim Cost. Identify and document deviations and trends to each PMG / Alianza assigned.
• Analyzes IBNR factors per PMG assigned.
• Submit and discusses monthly financial reports to the PMG / Alianza assigned with recommendations and establish, in conjunction with superior and the Medical Division, clinical and economical plans that will impact favorably to the PMG / Alianza and our members.
• With the utilization data, makes financial assumptions and analysis per group assigned. Collaborates with other internal departments to solve any potential discrepancies in compensation / financial reconciliations.
• Identify contracting and or sub capitation opportunities for each PMG / Alianza assigned.
• Monitor each PMG / Alianza assigned to ensure compliance with the contractual requirements.
• Maintain continuous communication with the PMG / Alianza assigned to advise on trends in utilization and other management issues that benefit the financial situation of these.
• Identify gaps and opportunities during the capitation evaluation process for each PMGs / Alianzas assigned. Ensure plans are identified and discussed with superiors to close gaps and discrepancies timely.

What You'll Bring

Master's degree preferable or Bachelor's Degree, with 5+ years of experience in senior executive level within health care industry preferable.

It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, sex, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company. Equality Employment Opportunity / Affirmative Action for People with Disabilities / Veterans". Employer with E-Verify to verify the eligibility of employment of all the new employees. We encourage Veterans and Disabled to apply.