Medical Reviewer II (Prior-Auth A/B MAC) - CGS

CGS Administrators, LLC • Grove City, OH • 2h ago

Internal Reference Number: R1049548
Summary Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices.Description
Why should you join the BlueCross BlueShield of South Carolina family of companies? 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 the largest insurance company in South Carolina ... and much more. 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 also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!
Logistics: CGS (cgsadmin.com) - one of BlueCross BlueShield of South Carolina's subsidiary companies.
Location:
Candidates who live within 40 miles of Nashville, TN, or Columbia, SC may be considered for a hybrid schedule.
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.
Work hours are 8:00 a.m. to 4:30 p.m. CT, Monday through Friday.
What You Will Do:
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 guidance, direction, and input as needed to LPN team members. 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.
To Qualify For This Position, You'll Need:
Required Licenses and Certificates: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).
Required Education: Associate in a job-related field OR graduate of an Accredited School of Nursing.
Required Work Experience: Two years of clinical nursing experience.
Required Skills and Abilities: Working knowledge of word processing software. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service and organizational skills. Demonstrated oral and written communication skills. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion.
Required Software and Tools: Microsoft Office.
We Prefer That You Have:
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, Med

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