CGS Administrators, LLC

Analyst

• Researches the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests.
• Provides thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines.
• Documents decisions within mandated timeframes and in compliance 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.

Appeals Analyst, Medicare Part B

Administration

• Directs and oversees operations in the medical review, clinical pricing, and re-determination areas
• Supervises and motivates area employees
• Coordinates tactical team activities
• Ensures area review decisions are accurate and associates are well informed and trained
• Reviews and analyzes data to create departmental strategy and error rate reduction plans
• Provides guidance on analysis, identification, and corrective actions for suspected program abuse
• Works closely with the Provider Service Center and other internal departments

Medical Review Director

Auditor

• Conduct audits of the financial, management, and administrative procedures of assigned divisions, providers, departments, and various lines of businesses throughout the organization to ensure that procedures are in compliance
• Audits include interviewing key personnel, conducting testing, evaluating internal controls, analyzing existing financial and management practices to determine effectiveness, and reviewing relevant documentation to support findings
• Develop detailed reports on each audit conducted
• Report includes a review of findings and an identification of recommendation to correct any deficiencies and methods for improvement to processes
• Conducts testing of corrective actions as identified
• Conduct special audit studies for management, such as those required to discover controls for prevention of fraud
• Prepare reports of finding and recommendations for management
• Assist other auditors in completing their assignments as a means of maximizing audit efficiency and thus reducing lost time and involvement of corporate personnel

Auditor I

Consultant

• Communicates/educates providers on issues such as Medicare coverage, utilization statistics, documentation and medical review by use of written advisories, reports, letters, and telephone contacts.
• Documents all provider contacts/communications in provider tracking system.
• Conducts formal conference calls and/or in-person educational visits with providers that are consistently over utilizing services, on progressive corrective action, or have unacceptable denial rates and/or error rates under the medical review program.
• Conducts coverage and documentation workshops for provider staff (Medicare providers and physicians' staff).
• Researches, composes, and coordinates the preparation of all regulatory based provider education materials.
• Performs analysis of effective reports to determine actions to be taken regarding medical reviewed its/audits.
• Determines what providers are over-utilizing services and what services are being over-utilized.
• Works with medical review department and provides input regarding actions taken in response to provider billing practices.
• Targets providers where greatest abuse of Medicare program has occurred.
• Participates in the medical review process and inter reviewer reliability (IRR) studies.
• Assists in training of medical review associates regarding coverage and medical review process.

Appeals Analyst, Medicare Part B

Medical Review Director

Auditor I

Senior Provider Education Consultant