Medical Reviewer III – Home Health and Hospice

Job not on LinkedIn

🔥 3 hours ago

🎸 Tennessee, Texas, +2 more states – Remote

🎸 Tennessee – Remote 🤠 Texas – Remote ⛷️ Utah – Remote 🍁 Vermont – Remote

💵 $51.1k - $97.7k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

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CGS Administrators, LLC

WebsiteLinkedInAll Job Openings

501 - 1000 employees

⚕️ Healthcare Insurance

🤝 B2B

Healthcare Insurance • B2B • Fraud Prevention

CGS Administrators, LLC is a company that provides scalable administrative services focused on optimizing operational performance and reducing costs for health plans. With over 50 years of experience, CGS delivers a range of services including credentialing, member services, claims processing, and fraud prevention to the Centers for Medicare & Medicaid Services (CMS) and various healthcare providers. Their aim is to streamline operations and enhance customer satisfaction, contributing positively to the healthcare delivery system.

📋 Description

• Performs medical claim reviews for 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 • Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement • 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. • 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

🎯 Requirements

• Required Education: Associate's in a job related field • Degree Equivalency: Graduate of Accredited School of Nursing • Required Experience: 2 years clinical plus 1 year utilization/medical review, quality assurance, or home health, OR 3 years clinical. • 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. • Knowledge of specific criteria/protocol sets and the use of the same. • 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. • Ability to persuade, negotiate, or influence others. • Analytical or critical thinking skills. • Ability to handle confidential or sensitive information with discretion. • Required Software and Tools: Microsoft Office. • Required Licenses and Certificates: 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.

🏖️ Benefits

• Subsidized health plans • Dental and vision coverage • 401k retirement savings plan with company match • Life Insurance • Paid Time Off (PTO) • On-site cafeterias and fitness centers in major locations • Education Assistance • Service Recognition • National discounts to movies, theaters, zoos, theme parks and more