Medical Record Reviewers

CGS has been a proven provider of administrative and business services for state Medicaid agencies, managed care organizations, commercial health plans, Medicaid members, Medicare beneficiaries, healthcare providers, and medical equipment suppliers for more than 50 years.

Selected candidates will be reviewing medical records to determine medical necessity, eligibility under Medicare guidelines and identify fraud and abuse of the Medicare system. This role will need strong clinical and computer skills. The role provides the opportunity for a good home/work life balance with a Monday through Friday daytime schedule, some flexibility, and no regular weekends or holidays.Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We deliver outstanding service to our customers. Logistics: CGS (cgsadmin.Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.

Qualified candidates outside the local area will also be considered for a work from home schedule. You must have high-speed internet (non-satellite) and a private home office to work from home.

CT, Monday through Friday.

Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations. Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. Determines medical necessity, appropriateness, and/or reasonableness and necessity for coverage and reimbursement. Monitors process's timeliness in accordance with contractor standards. Documents medical rationale to justify payment or denial of services and/or supplies.

Educates internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc., in accordance with contractor guidelines.

Participates in quality control activities in support of the corporate and team-based objectives. Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback. Assists with special projects and specialty duties/responsibilities as assigned by management.

Associate in a job-related field OR graduate of an Accredited School of Nursing.

Required Work Experience: Two years of clinical nursing experience.

Working knowledge of word processing software. Demonstrated customer service and organizational skills. Ability to handle confidential or sensitive information with discretion.

Required Software and Tools: Microsoft Office.

Five years of clinical experience as a Registered Nurse, including two years in the following specialty area(s): Outpatient Surgical, Pain Management, Cosmetic Surgery, Prior Authorization, Medical Review, Medicare Part A, or Utilization Management.

Ability to work with multiple Windows-based programs simultaneously.

Intermediate Word, Excel, and Outlook skills.

Subsidized health plans, dental and vision coverage

• 401k retirement savings plan with company match
• Life Insurance
• On-site cafeterias and fitness centers in major locations
• After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.

Compensation decisions within the range will be dependent upon a variety of factors, including experience, geographic location, and internal equity.

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilitiesand protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

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