Medical Reviewer II; Prior-Auth A​/B MAC - CGS

Medical Reviewer II (Prior-Auth A/B MAC) - CGS

$47,263 – $90,548

Location:

United States, New York

Selected candidates will review medical records to determine medical necessity, eligibility under Medicare guidelines, and identify fraud and abuse of the Medicare system. The role requires strong clinical and computer skills, self‑motivation, and excellent time management. It offers a good work‑life balance with a Monday – Friday daytime schedule and no regular weekends or holidays.

This range represents the pay range for this position and other positions that fall into this pay grade. Compensation within the range will be dependent upon a variety of factors, including experience, geographic location, and internal equity.

Hybrid schedule may be available for candidates living within 40 miles of Nashville, TN or Columbia, SC. Qualified candidates outside the local area may work from home and must have high‑speed internet (non‑satellite) and a private home office. Work hours are 8:00 a.m. – 4:30 p.m. CT, Monday through Friday.

Company: CGS (), a subsidiary of Blue Cross Blue Shield of South Carolina. Security clearance is required; applicant must be a U.S. citizen. This position is not eligible for sponsorship now or in the future.

• Perform medical claim reviews for medically complex services, preauthorization, appeals, referrals for potential fraud or abuse, and correct coding. Make charge payment determinations based on clinical information and established criteria.
• Educate internal and external staff on medical reviews, terminology, coverage determinations, coding procedures, and related contractor guidelines.
• Participate in quality control activities, provide guidance to LPN team members, deliver education to non‑medical staff, and assist with special projects as assigned.

• Required Licenses:
  Active RN licensure in the state of hire or an active compact multistate RN license.
• Required
  
  Education:
  
  Associate degree in a related field or graduate of an accredited nursing school.
• Required
  
  Work Experience:
  
  Two years of clinical nursing experience.
• Required Skills:
  
  Proficiency in word processing, independent work, prioritization, sound decision‑making, good judgment, customer service, organization, oral and written communication, analytical or critical thinking, and discretion with confidential information.
• Required Software:
  Microsoft Office.

• Five years of RN clinical experience, with at least two years in specialty areas such as Outpatient Surgical, Pain Management, Cosmetic Surgery, Prior Authorization, Medical Review, Medicare Part A, or Utilization Management.
• Ability to use multiple Windows‑based programs simultaneously.
• Intermediate Word, Excel, and Outlook skills.

• Subsidized health, dental, and vision plans.
• 401(k) retirement savings plan with company match.
• Life insurance.
• Paid Time Off (PTO).
• On‑site cafeterias and fitness centers in major locations.
• Education assistance.
• Service recognition.
• National discounts to movies, theaters, zoos, theme parks, and more.

Blue Cross Blue Shield of South Carolina and its subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information, or any other legally protected status. As a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans.

The company provides equal opportunities in all phases of the employment process and complies with applicable federal, state, and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy‑related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the company.

We participate in E‑Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.