RN Medical Reviewer II (DME) – CGS

CGS is looking for Registered Nurses to join our DME (Durable Medical Equipment) Medicare Medical Review team. Selected candidates will be reviewing medical records to determine medical necessity and eligibility under Medicare guidelines. This administrative role will need strong clinical and computer skills. No regular patient/provider contact. Excellent for those individuals looking to transition their career from direct patient care to working from home.

• This is a work from home opportunity. To work from home, you must have high-speed internet (non-satellite) and a private home office.
• Work hours are 8:00 am to 5:00 pm CT. Monday through Friday.

• 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 and 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/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.

• Required Licenses and Certificates: Active, unrestricted RN licensure from the United States and in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact NLC),
• Required Education: Associates in a job-related field OR graduate of Accredited School of Nursing.
• Required Work Experience: Two years of clinical nursing experience.
• Required Skills and Abilities: Working knowledge of word processing software. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service and organizational skills. Demonstrated oral and written communication skills. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion.
• Required Software and Tools: Microsoft Office.

• One-year Medical Review experience.
• DME (Durable Medical Equipment) experience.
• Administrative experience in Health Care Quality Assurance, Medical Insurance, Utilization Review, or Case Management.
• Five years clinical experience as a Registered Nurse.

• 401(k) retirement savings plan with company match.
• Subsidized health plans and free vision coverage.
• Life insurance.
• Paid annual leave – the longer you work here, the more you earn.
• Nine paid holidays.
• On-site cafeterias and fitness centers in major locations.
• Wellness programs and healthy lifestyle premium discount.
• Tuition assistance.
• Service recognition.
• Incentive Plan.
• Merit Plan.
• Continuing education funds for additional certifications and certification renewal.