CGS Administrators, LLC

Customer Support

• Provides prompt, accurate, thorough and courteous responses to all customer inquiries
• Performs research as needed to resolve inquiries
• Ensure effective customer relations by responding accurately, timely and courteously to inquiries
• Accurately document inquiries
• Initiate or process adjustments or perform other research as needed
• Coordinates with other departments to resolve problems
• Respond to, research and/or assist with priority inquiries and special projects
• Provide feedback to management regarding customer problems, questions and needs
• Maintain accurate records on complaints and/or other customer comments
• Follow through on complaints until resolved or report to management as needed
• Maintain basic knowledge of quality work instructions and company policies
• Assist with process improvements through recommendations
• Maintain all departmental productivity, quality, and timeliness standards
• Identify and promptly report suspected fraudulent activities and system errors to appropriate departments

Customer Service Advocate

Administration

• Develops comprehensive reports and analyzes data in order to identify patterns and trends
• Assists in creating materials that aid in illustrating analytical/data findings
• Assists with sophisticated data interpretation, compilation, and verification to guide departmental efforts
• Designs, codes, maintains and executes simple to complex database programs for the extraction and presentation of data for standard and ad hoc reporting
• Utilizes statistical programming tools to identify patterns and trends in data
• Assists in sampling design, sample selection, and relevant projections
• Performs statistical validations of sampling and related projections
• Assists with the preparation of charts, illustrations, other graphics and narrative reports to explain findings
• Assists with the development of complex statistical analysis, including standard reporting, AD HOC reporting, and data mining tools
• Provides assistance in development of project plans and system life cycle maintenance, development of change requests and test plans impacting existing databases, and in the research of new sources for data
• Verifies data in existing databases and assists in the collection of data and management of existing databases
• Creates supporting documentation outlining procedures within scope of responsibility

Statistical Programming Analyst II

Accounting Manager

• Identify, investigate, and recover incorrectly paid medical claims by analyzing payment data.
• Verify overpayments from sources like duplicate payments or system errors.
• Document findings and coordinate with providers for reimbursement or adjustments according to Medicare guidelines.
• Prepare correspondence, create, and update accounts receivables.
• Review reports.
• Complete moderately difficult to complex research using financial reporting systems.
• Resolve most questions and problems, referring most complex issues to higher levels.
• Perform calculations on financial documents to ensure accuracy of bank deposits, receipts, disbursements, refunds, or other accounting-related items.
• Provide other support duties related to the accounting/finance function including monitoring financial systems, tracking funds, and maintaining inventory.
• Assist less experienced accounting clerks as needed.
• Prepare journal entries and account reconciliations and respond to inquiries from internal and external customers.

Accounting Technician III

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

Cost Auditor – Entry Level

• 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

General

• Performs non-medical reviews and processes redetermination letters ensuring timeliness and accuracy.
• Prepares unit reports, analyzes and interprets workload, and processes issues utilizing various software tools.
• Updates letters and documents within the department when necessary.
• May gather and prepare documentation for legal inquiries and administrative requests.

Appeals Specialist – CGS Admin

• Provides prompt, accurate, thorough and courteous responses to all customer inquiries
• Performs research as needed to resolve inquiries
• Ensure effective customer relations by responding accurately, timely and courteously to inquiries
• Accurately documents inquiries
• Initiate or processes adjustments or perform other research as needed to resolve inquiries
• Coordinates with other departments to resolve problems
• Responds to, research and/or assists with priority inquiries and special projects as required by management
• Provide feedback to management regarding customer problems, questions and needs
• Maintains accurate records on complaints and/or other customer comments
• Follows through on complaints until resolved or reports to management as needed
• Maintains all departmental productivity, quality, and timeliness standards
• Identify and promptly report and/or refer suspected fraudulent activities and system errors to the appropriate departments

Customer Service Advocate II

Medical Reviewer

• 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

Medical Reviewer III – Home Health and Hospice

• Conduct internal and/or external operational, financial, and/or compliance audits
• Identify, document, and evaluate business risks
• Develop written audit programs
• Prepare written work papers to document testing results
• Write audit reports for corporate executive management
• Collect and analyze data to detect deficient controls
• Conduct testing of corrective actions identified
• Examine and evaluate financial and information systems
• Provide training to other auditors

Auditor III

• Performs non-medical reviews and processes redetermination letters ensuring timeliness and accuracy
• Prepares unit reports, analyzes and interprets workload, and processes issues utilizing various software tools
• Updates letter's and documents within the department when necessary
• May gather and prepare documentation for legal inquiries and administrative requests

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Customer Service Advocate I

• Provide all redetermination case file information within the specified time requirement
• Compile and provide documentation packets for QIC requests
• Validate and process reconsideration requests within designated timeliness and quality standards
• Identify, retrieve, and prepare documentation for batching
• Maintain databases and tracking systems to ensure timeliness and quality standards are met

Assistant, Qualified Independent Contractor

• Prepares various financial data associated with refunds, invoices, recoupments, adjustments, cash disbursements, deposits, check voids and reissues, disputes, correspondence, or other data in support of the finance or accounting function.
• Ensures data is complete, accurate, and organized for processing.
• Provides supervisor with daily, weekly, and/or monthly summary reports of accounting activities for the position.
• Completes moderately difficult research using financial reporting systems, files, and other means to identify errors such as overpayments or misapplication of funds.
• Resolves routine questions and problems, referring 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, keying journal entries, tracking funds, balancing accounts, maintaining inventory and receiving cash funds from customers, etc.
• May assist less experienced accounting clerks as needed.
• Determines, prepares, and distributes correspondence regarding monies due or erroneously received.
• Issues refunds as appropriate.

Accounting Technician II

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

Medical Director

• Supports operations in the form of case review on both medical and regulatory matters.
• Develops claim adjudication criteria for situations requiring medical judgment.
• Provides input on issues and operational policies, processes, and procedures.
• Educates staff and medical community on various aspects of medical policy and program administration.
• May develop and update medical policy in consultation with appropriate regulatory personnel, medical consultants, and professional societies.
• Develops external relationships with the medical community and serves as liaison between these entities and the contractors.
• Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization.
• Conducts research into new or controversial medical procedures and technology.

Customer Service Advocate

Statistical Programming Analyst II

Accounting Technician III

Cost Auditor – Entry Level

Auditor I

Appeals Specialist – CGS Admin

Customer Service Advocate II

Medical Reviewer III – Home Health and Hospice

Auditor III

Appeals Specialist – CGS Admin

Customer Service Advocate I

Assistant, Qualified Independent Contractor

Accounting Technician II

RN Appeals Analyst, Medicare Part B

Chief Medical Officer – Medicare Policy