Rn Medical Reviewer Iii - Cgs Administrators

Summary

Join our team in performing medical reviews of Medicare DME (Durable Medical Equipment) cases. 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

CGS Administrators provides a variety of services, under contracts with the Centers for Medicare and Medicaid Services (CMS) for beneficiaries, health care providers, and medical equipment suppliers in 33 states, supporting the needs of more than 20 million Medicare beneficiaries nationwide. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Want to work for a growing company with an innovative eye towards the future? Join us today!

What You’ll Do

• Assist with special projects and specialty duties/responsibilities as assigned by Management.
• Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Provide education to non-medical staff through discussions, team meetings, classroom participation and feedback.
• Provide guidance, direction, and input as needed to RN team members.
• Perform medical claim reviews for one or more of the following: claims for medically complex services, services that require pre-authorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/operations.
• Participate in quality control activities in support of the corporate and team-based objectives.
• Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement.
• Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
• Document medical rationale to justify payment or denial of services and/or supplies.

To Qualify For This Position, You’ll Need

• Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR, current active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area.
• Ability to work independently, prioritize effectively, and make sound decisions.
• Good judgment skills.
• Working knowledge of managed care and various forms of health care delivery systems; strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience.
• Demonstrated customer service and organizational skills.
• Working knowledge of word processing software.
• Analytical or critical thinking skills .
• Knowledge of specific criteria/protocol sets and the use of the same.
• Associate Degree Nursing, OR Graduate of accredited School of Nursing.
• Demonstrated oral and written communication skills.
• Microsoft Office.
• Two years clinical plus one year utilization/medical review, quality assurance, or home health, OR three years clinical.
• Ability to handle confidential or sensitive information with discretion.
• Ability to persuade, negotiate, or influence others.

What We Prefer You Have

• Medicare experience.
• Utilization Review or Case Management experience.

What Blue Can Do For You

Our comprehensive benefits package includes:

• Wellness programs and a healthy lifestyle premium discount
• Nine paid holidays
• 401(k) retirement savings plan with company match
• Subsidized health plans and free vision coverage
• Tuition assistance
• On-site cafeterias and fitness centers in major locations
• Service recognition
• Paid annual leave — the longer you work here, the more you earn
• Life insurance

What To Expect Next

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. Management will be conducting interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

Equal Employment Opportunity Statement

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 minorities, females, disabled individuals and 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 physical and mental disabilities.

If you need special assistance or an accommodation while seeking employment, please e-mail [email protected] or call 1-800-288-2227, ext. 43172 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.