CGS Administrators, LLC

Customer Support

• Respond accurately, timely, and courteously to telephone, written, web, or walk-in inquiries.
• Handle situations which may require adaptation of response or extensive research.
• Identify incorrectly processed claims and process adjustments and reprocessing actions according to department guidelines.
• Examine and process claims and/or non-medical appeals according to business/contract regulations, internal standards and examining guidelines.
• Enter claims into the claim system after verification of correct coding of procedures and diagnosis codes.
• Ensure claims are processing according to established quality and production standards.
• Identify complaints and inquiries of a complex level that cannot be resolved following desk procedures and guidelines and refer these to a lead or manager for resolution.
• Identify and report potential fraud and abuse situations.

Claims Customer Service Advocate II

Medical Reviewer

• 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, 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 and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc., in accordance with contractor guidelines
• 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

Medical Reviewer II – Prior-Auth A/B MAC

Administration

• Provides supervision and direction of the statistical reporting function and data analysis to support clinical reporting function
• Monitors adherence to statistical reporting requirements, updates systems as necessary
• Sets and maintains general direction/focus of statistical reporting function
• Perform analysis and reporting including performing clinical trend analysis
• Develop reports through various data reporting tools
• Develop data driven solutions to improve outcomes
• Collaborate with other areas to reduce expense through data analysis, including gathering business requirements, documentation, testing, and delivery of reporting
• Serve as internal subject matter expert and point of contact for query/design for clinical analysis
• Identifies data analysis needs based on customer
• Supervises staff including directing work, addressing performance, and providing training
• Review work and coaches subordinates

Clinical Reporting Supervisor

Analyst

• Research the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests.
• Provide thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines.
• Document decisions within mandated timeframes and in compliance with applicable regulations or standards.
• Perform thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements, governing agencies, policies and procedures, while adhering to confidentiality regulations regarding protected health information.
• Perform appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and or application to benefit or policy provisions.
• Perform special projects including reviews of clinical information to identify quality of care issues.

RN Appeals Analyst

• Documents the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards.
• Performs thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements, governing agencies, policies and procedures, while adhering to confidentiality regulations regarding protected health information.
• Performs appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and or application to benefit or policy provisions.
• Performs special projects including reviews of clinical information to identify quality of care issues.

RN Appeals Analyst, Medicare Part B

Auditor

• Conducts internal and/or external timely operational, financial, and/or compliance audits of divisions, departments, providers, and activities of the corporation
• Identifies, documents, and evaluates business risks
• Develops written audit programs
• Conducts testing and analysis of existing controls to determine adequacy and effectiveness
• Prepares written work papers to document testing results and conclusions reached
• Documents issues, the causes of those issues, and their effects on the process/function and the corporation
• Serves as Lead Auditor on more complex audit assignments
• Drafts recommendations to limit risks and improve processes, functions and activities
• Writes audit reports for corporate executive management
• Collects and analyzes data to detect deficient controls, duplicated effort, fraud, or non-compliance with laws
• Conducts testing of corrective actions as identified
• Develops detailed reports on each audit conducted
• Prepares reports of findings and recommendations for management
• Provides training to and assists or leads other auditors in completing their assignments

Auditor III

• Research the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests
• Provide thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines
• Document decisions within mandated timeframes and in compliance with applicable regulations or standards
• Perform thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements, governing agencies, policies and procedures
• Perform appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in the application of policies and procedures to clinical information and or application to benefit or policy provisions
• Perform special projects including reviews of clinical information to identify quality of care issues

Manager

• Oversees the accurate processing of claims that have been deferred for medical necessity review
• Ensures compliance with nationally recognized standards, and local, state, and federal laws and regulations
• Identifies and implements process improvement opportunities
• Manages and oversees the accurate processing of claims deferred for medical necessity review
• Drives continuous improvement by identifying and implementing process enhancements
• Supports team accountability and maintains high-quality performance standards
• Interfaces with internal and external customers such as appellants/attorneys, congressional offices, and other regulatory bodies as required

Manager, Medical Review – Medicare, Appeals, Utilization Review, Part A, HHH

Accounting Manager

• Complete Accounts Payable function including posting vouchers, check posting and coordination of payments with vendors
• Obtain approvals for invoices through multiple managers
• Manage the AP emails for approvals
• Process EFT and check payments
• Complete monthly close journal entries associated with AP or accruals
• Manage the P-card process by booking hotels and processing payments using the company card
• Reconcile the credit card statement for all corporate cards for CGS
• Prepares various in-depth financial data associated with refunds, invoices, recoupments, adjustments, cash disbursements, deposits, check voids and reissues
• Ensures data is complete, accurate, and organized for processing
• Provides supervisor with daily, weekly, and/or monthly summary reports of accounting activities
• Completes moderately difficult to complex research using financial reporting systems to identify errors such as overpayments or misapplication of funds
• Resolves most questions and problems, referring most complex issues to higher levels.
• Performs calculations on financial documents to ensure accuracy of bank deposits, receipts, disbursements, refunds, or other accounting-related items
• Provides other support duties related to the accounting/finance function that may include monitoring financial systems, tracking funds, balancing accounts, and maintaining inventory.

Claims Customer Service Advocate II

Medical Reviewer II – Prior-Auth A/B MAC

Clinical Reporting Supervisor

RN Appeals Analyst

RN Appeals Analyst, Medicare Part B

Auditor III

RN Appeals Analyst

Manager, Medical Review – Medicare, Appeals, Utilization Review, Part A, HHH

Accounting Technician III, Accounts Payable