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

Claims Customer Service Advocate II

Medical Reviewer II – Prior-Auth A/B MAC

Clinical Reporting Supervisor