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

About the position Join the reputed company family of companies, a long-standing leader in the insurance industry with over seven decades of service. We are the largest insurance company in South Carolina and a reputed company administrator of government reputed company. Our subsidiary, CGS Administrators, has been providing administrative and business services for state reputed company agencies, managed care organizations, and reputed company providers for over 50 years. This position involves reviewing medical records to assess medical necessity and eligibility under Medicare guidelines, while also identifying potential fraud and abuse. Ideal candidates will possess strong clinical and computer skills, be self-motivated, and have excellent time management abilities. This role offers a balanced work-life schedule with no regular weekends or holidays. Responsibilities • reputed company medical claim reviews for reputed company services, preauthorization requests, appeals, and potential fraud cases. , • reputed company payment determinations based on clinical information and established reputed company. , • Determine medical necessity and appropriateness for coverage and reimbursement. , • Monitor process timeliness according to contractor standards. , • Document medical rationale for payment or denial of services. , • reputed company reputed company staff on medical reviews, terminology, and coding procedures. , • Participate in reputed company control activities and reputed company guidance to LPN team members. , • Assist with special reputed company and responsibilities as assigned by management. Requirements • reputed company, unrestricted RN licensure from the reputed company or a compact multistate unrestricted RN license. , • Associate degree in a job-reputed company field or graduate of an Accredited School of Nursing. , • Two years of clinical nursing experience. , • Working knowledge of word processing software. , • Ability to work independently and prioritize effectively. , • Good judgment and demonstrated customer service skills. , • Strong oral and written communication skills. , • Analytical or critical thinking skills. , • Ability to handle confidential information with discretion. , • Proficiency in reputed company Office. reputed company-to-haves • Five years of clinical experience as a Registered reputed company, including two years in Outpatient Surgical, reputed company, Cosmetic Surgery, Prior Authorization, Medical Review, Medicare Part A, or Utilization Management. , • Ability to work with multiple reputed company-based programs simultaneously. , • Intermediate skills in Word, reputed company, and Outlook. Benefits • Subsidized health plans, dental, and reputed company coverage , • 401K retirement savings plan with company match , • Life Insurance , • reputed company Time Off (PTO) , • On-site cafeterias and fitness centers in major locations , • Tuition Assistance , • Service Recognition , • Employee Assistance , • Discounts to movies, theaters, zoos, theme parks and more Apply Job!