CGS Administrators, LLC

Auditor

• Conducts 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
• Develops detailed reports on each audit conducted
• Reports include 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
• Conducts special audit studies for management, such as those required to discover controls for prevention of fraud
• Prepares reports of finding and recommendations for management
• Assists 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

Claims Specialist

• Reviews and adjudicates complex or specialty claims.
• Determines whether to return, deny or pay claims following organizational policies and procedures.
• Assists in training or mentoring new staff members.
• Examines and processes complex or specialty claims according to business/contract regulations, internal standards and examining guidelines.
• Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes.
• Verifies that claims have been keyed correctly.
• Ensures that claims are processing according to established quality and production standards.
• Corrects processing errors by reprocessing, adjusting, and/or recouping claims.
• Researches and resolves claims edits and deferrals.
• Performs research on claim problems by utilizing policies, procedures, reference materials, forms and coordinates with various internal support areas.
• Responds to routine correspondence and completes spreadsheet if applicable.

Claims Processor II

• Conducts internal and external timely operational, compliance, and financial audits of divisions, departments, providers, and activities of the corporation including evaluation of internal controls.
• Identifies, documents, and evaluates business risks.
• Documents issues, the causes of those issues, and their effects on the process/function and the corporation.
• Drafts recommendations to limit risks and improve processes, functions and activities.
• Writes audit reports for corporate executive management that clearly and effectively convey engagement evaluations, conclusions, and recommendations.
• Collects and analyzes data to detect deficient controls, duplicated effort, fraud, or non-compliance with laws, regulations, and management policies.
• Conducts testing of corrective actions as identified.
• Develops detailed reports on each audit conducted.
• Reports include a review of findings and an identification of recommendation to correct any deficiencies and methods for improvement to processes.
• Examines and evaluates financial and information systems, recommending controls to ensure system reliability and data integrity.
• Conducts special audit studies for management, such as those required to discover controls for prevention of fraud.
• Prepares reports of findings and recommendations for management.
• Assists other auditors in completing their assignments as a means of maximizing audit efficiency and thus reducing lost time and involvement of corporate personnel.

Auditor II

Customer Support

• Provides prompt, accurate, thorough and courteous responses to all customer inquiries
• Performs research as needed to resolve inquiries
• Accurately documents inquiries
• Initiates or processes adjustments or performs other research as needed to resolve inquiries
• Coordinates with other departments to resolve problems
• Responds to, researches and/or assists with priority inquiries and special projects as required by management
• Provides feedback to management regarding customer problems, questions and needs
• Maintains accurate records on complaints and/or other customer comments, and makes recommendations for changes to management
• Follows through on complaints until resolved or reports to management as needed
• Maintains basic knowledge of quality work instructions and company policies
• Assists with process improvements through the recommendation of changes in procedures and techniques discovered during daily operations
• Maintains all departmental productivity, quality, and timeliness standards
• Identifies and promptly reports and/or refers suspected fraudulent activities and system errors to the appropriate departments

Customer Service Advocate I

• Reviews and adjudicates complex or specialty claims
• Determines whether to return, deny or pay claims following organizational policies and procedures
• Assists in training or mentoring new staff members
• Examines and processes complex or specialty claims according to business/contract regulations, internal standards and examining guidelines
• Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes
• Verifies that claims have been keyed correctly
• Ensures that claims are processing according to established quality and production standards
• Corrects processing errors by reprocessing, adjusting, and/or recouping claims
• Researches and resolves claims edits and deferrals
• Performs research on claim problems by utilizing policies, procedures, reference materials, forms and coordinates with various internal support areas
• Responds to routine correspondence and completes spreadsheet if applicable