Coordinates the quality control program for the medical review area. Researches the Center for Medicare and Medicaid services (CMS) changes. Trains new staff and provides continuing education to clinical staff.
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!
Here are just some of our benefits:
- Paid annual leave – the longer you work here the more you earn
- 9 paid holidays
- 401(k) retirement savings plan with company match
- Education assistance
Want to work for a growing company with an innovative eye towards the future? Join us today!
What you will do:
Reviews medical review decisions for accuracy and to ensure CMS instructions have been applied correctly. Develops/implements the quality control program used as an intense review of clinical staff’s technical knowledge and evaluation of medical judgment ability. Provides feedback to management and staff and if necessary provides remedial training. Assists provider service departments with medical coverage issues to ensure continuity of application of CMS guidelines. Responds to specific provider inquiries and appeals requests. Develops and maintains departmental reference manuals used for proper application of CMS instructions.
Provides continuing education workshops on coverage issues and medical advances. Trains new staff on CMS guidelines and medical review procedures. Coordinates system access and security clearance of new staff. Creates monthly reports for management outlining quality control results adjustment data and reopen results summary. Provides input to medical review audit department regarding actions taken in response to provider billing practices in order to target program abuse.
What you need to qualify:
- Associate Degree – Nursing or Graduate of an Accredited School of Nursing.
- Four years combination of clinical utilization review training quality assurance or case management experience. (Preference given to candidates with 3-5 years of Medicare Part A Medical Review or Appeals experience)
- Excellent verbal and written communication customer service organizational and analytical or critical thinking.
- Good judgment.
- Proficient spelling grammar punctuation and basic business math.
- Ability to persuade negotiate or influence and handle confidential or sensitive information with discretion.
- Knowledge of mathematical or statistical concepts and medical terminology.
- Microsoft Office.
- Active unrestricted RN licensure in state hired OR active unrestricted compact multistate RN license as defined by the Nurse Licensure Compact (NLC).
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 firstname.lastname@example.org 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.