Medical Reviewer II (Prior-Auth A/B MAC) – CGS
Posted 2025-08-26
Remote, USA
Part Time
Immediate Start
About the position
Responsibilities
• Perform medical claim reviews for complex services, preauthorization requests, appeals, and potential fraud cases.
• Make payment determinations based on clinical information and established criteria.
• Determine medical necessity and appropriateness for coverage and reimbursement.
• Monitor process timeliness according to contractor standards.
• Document medical rationale for payment or denial of services.
• Educate internal and external staff on medical reviews, terminology, and coding procedures.
• Participate in quality control activities and provide guidance to LPN team members.
• Assist with special projects and responsibilities as assigned by management.
Requirements
• Active, unrestricted RN licensure from the United States or a compact multistate unrestricted RN license.
• Associate degree in a job-related field or graduate of an Accredited School of Nursing.
• Two years of clinical nursing experience.
• Working knowledge of word processing software.
• Ability to work independently and prioritize effectively.
• Good judgment and demonstrated customer service skills.
• Strong oral and written communication skills.
• Analytical or critical thinking skills.
• Ability to handle confidential information with discretion.
• Proficiency in Microsoft Office.
Nice-to-haves
• Five years of clinical experience as a Registered Nurse, including two years in Outpatient Surgical, Pain Management, Cosmetic Surgery, Prior Authorization, Medical Review, Medicare Part A, or Utilization Management.
• Ability to work with multiple Windows-based programs simultaneously.
• Intermediate skills in Word, Excel, and Outlook.
Benefits
• Subsidized health plans, dental, and vision coverage
• 401K retirement savings plan with company match
• Life Insurance
• Paid Time Off (PTO)
• On-site cafeterias and fitness centers in major locations
• Tuition Assistance
• Service Recognition
• Employee Assistance
• Discounts to movies, theaters, zoos, theme parks and more
Apply to This Job
Responsibilities
• Perform medical claim reviews for complex services, preauthorization requests, appeals, and potential fraud cases.
• Make payment determinations based on clinical information and established criteria.
• Determine medical necessity and appropriateness for coverage and reimbursement.
• Monitor process timeliness according to contractor standards.
• Document medical rationale for payment or denial of services.
• Educate internal and external staff on medical reviews, terminology, and coding procedures.
• Participate in quality control activities and provide guidance to LPN team members.
• Assist with special projects and responsibilities as assigned by management.
Requirements
• Active, unrestricted RN licensure from the United States or a compact multistate unrestricted RN license.
• Associate degree in a job-related field or graduate of an Accredited School of Nursing.
• Two years of clinical nursing experience.
• Working knowledge of word processing software.
• Ability to work independently and prioritize effectively.
• Good judgment and demonstrated customer service skills.
• Strong oral and written communication skills.
• Analytical or critical thinking skills.
• Ability to handle confidential information with discretion.
• Proficiency in Microsoft Office.
Nice-to-haves
• Five years of clinical experience as a Registered Nurse, including two years in Outpatient Surgical, Pain Management, Cosmetic Surgery, Prior Authorization, Medical Review, Medicare Part A, or Utilization Management.
• Ability to work with multiple Windows-based programs simultaneously.
• Intermediate skills in Word, Excel, and Outlook.
Benefits
• Subsidized health plans, dental, and vision coverage
• 401K retirement savings plan with company match
• Life Insurance
• Paid Time Off (PTO)
• On-site cafeterias and fitness centers in major locations
• Tuition Assistance
• Service Recognition
• Employee Assistance
• Discounts to movies, theaters, zoos, theme parks and more
Apply to This Job