Claims Review Administrative Specialist

Fully Remote • 699 INDUSTRIAL AVE - ISABELLA, PR 00662

About the Role

Capitol Bridge Puerto Rico is seeking a detail-oriented Claims Review Administrative Specialist to support the Florida CDR and multi-state IRO programs. This non-clinical role is responsible for case intake, document control, correspondence, tracking, and administrative case progression so clinical, coding, and legal reviewers can focus on substantive review work. The position helps ensure cases are complete, accurately documented, and moved through each stage within required timelines.

Payrate: $20/hr

Key Responsibilities

• Receive, log, organize, and perform administrative intake of incoming claim dispute cases and supporting documentation.
• Review case files for administrative completeness and identify missing, unreadable, or inconsistent documentation for follow-up.
• Maintain accurate case status, correspondence, dates, assignments, and documentation in program systems and trackers.
• Prepare and organize case packets for RN reviewers, coding specialists, physicians, attorneys, and other credentialed reviewers.
• Route cases and documentation according to established workflows and escalation procedures.
• Monitor case aging, due dates, and required turnaround times; escalate cases at risk of delay.
• Conduct administrative outreach to providers, health plans, enrollees, or other parties using approved procedures and templates.
• Prepare standard notices, correspondence, and determination packages for review and distribution.
• Support case reconciliation, reporting, audit requests, and Quality Assurance/Quality Control activities.
• Protect confidential information and comply with applicable privacy, security, project, and company requirements.
• Participate in required meetings, training, process updates, and implementation of regulatory or client-directed changes.

Required Qualifications

• High school diploma or equivalent.
• Two or more years of administrative, healthcare, claims, insurance, medical office, case support, or comparable experience.
• Strong attention to detail and ability to manage multiple cases and deadlines simultaneously.
• Proficiency with Microsoft Outlook, Word, Excel, PDFs, and electronic document repositories.
• Strong written and verbal communication skills in English.
• Ability to handle sensitive and confidential healthcare information appropriately.

Preferred Qualifications

• Experience supporting healthcare claims, appeals, disputes, utilization review, medical records, or payer/provider operations.
• Familiarity with medical terminology, Explanation of Benefits (EOBs), CPT codes, or healthcare billing documentation.
• Experience with SharePoint, ShareFile, case management systems, or similar repositories.
• Bilingual English/Spanish communication skills.

What Success Looks Like

Cases do not sit because of administrative barriers. Files are complete and organized, statuses are accurate, deadlines are visible, reviewers receive the information they need, and risks are escalated before they become missed requirements.

Required Screenings

Employment is contingent upon successful completion of applicable background screening requirements.

Reasonable Accommodation

Reasonable accommodation may be made to enable qualified individuals with disabilities to perform the essential functions of this position. Additional duties may be assigned based on program needs.

Equal Employment Opportunity

Capitol Bridge Puerto Rico is an Equal Opportunity Employer. Employment decisions are based on business needs, job requirements, and individual qualifications, without regard to any status protected by applicable law.