Special Needs Plan Program Specialist

About the role

This position performs health risk assessments (HRAs) to determine whether members are eligible for Special Supplemental Benefits for the Chronically Ill (SSBCI). It also reviews each member's individualized care plan and carries out targeted interventions to monitor their health status.

Key responsibilities

• Perform health risk assessments for all members referred for SSBCI within the established time frame.
• Call the most vulnerable members by phone to monitor their health status and compliance with their care plan.
• Alert management to deficiencies or opportunities for improvement so processes remain clear.
• Contact members by phone to complete assessments and provide referrals, and contact physicians when additional medical information is needed.
• Identify potential cases for intervention by the appropriate area and receive and direct incoming calls from members and physicians.
• Ensure situations involving physicians or members are promptly referred so the HRA can be completed.
• Communicate the final assessment determination in line with departmental policies and within set time limits.
• Maintain reports and productivity metrics and meet production, quality and timeline requirements.

Required profile

• Bachelor of Science in Nursing (BSN).
• At least three years of experience in clinical areas, including documentation or analysis of health conditions.
• Valid license and registration for nursing practice in Puerto Rico.
• Intermediate Spanish and English, comprehensive in writing and speaking.