Summary
 

CGS is looking for Registered Nurses to join our DME (Durable Medical Equipment) Medicare Medical Review team. Selected candidates will be reviewing medical records to determine medical necessity and eligibility under Medicare guidelines. This administrative role will need strong clinical and computer skills. No regular patient/provider contact. Excellent for those individuals looking to transition their career from direct patient care to working from home.

To be successful, you will need to have clinical, critical thinking, time management and windows-based computer skills. The position will be computer based.

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, 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 that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

This open position is within one of our subsidiary companies called CGS Administrators. 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.

Description
 

Logistics:

• Preferred candidate will live in Nashville, TN area. For those living in Nashville, the position would be hybrid (in-office and work from home).

• Highly qualified candidates outside the Nashville area will also be considered. For those living outside Nashville area, the position will be fully remote.

• To work from home, you must have high-speed (non-satellite) internet and a private home office.

Location:

• If you live within 30 miles of Nashville, TN position will be hybrid.  For those living outside this area the position will be fully remote.

Position Purpose:

• 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.

What You’ll 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 and 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/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.