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

June 6, 2026

<h1> Summary </h1>This open position is within one of our subsidiary companies called CGS Administrators. CGS has been a proven provider of administrative and business services for state Medicaid agencies, managed care organizations, commercial health plans, Medicaid members, Medicare beneficiaries, healthcare providers, and medical equipment suppliers for more than 50 years. Selected candidates will be reviewing medical records to determine medical necessity, eligibility under Medicare guidelines and identify fraud and abuse of the Medicare system. This role will need strong clinical and computer skills. It will be best for someone who is self-motivated and has excellent time management skills. Excellent for those individuals looking to transition their career from the physical and time demands of direct patient care. The role provides the opportunity for a good home/work life balance with a Monday through Friday daytime schedule, some flexibility, and no regular weekends or holidays.<h1> Description </h1>Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!<div><div><div><div><div><div><div><div><div><div>Logistics: <a href="https://cgsadmin.com/" target="_blank" rel="noopener noreferrer">CGS (cgsadmin.com)</a> – one of BlueCross BlueShield of South Carolina’s subsidiary companies.Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.Sponsorship: This position is not eligible for sponsorship now or in the future. Location:<ul><li>Candidates who live within 40 miles of Nashville, TN, or Columbia, SC may be considered for a hybrid schedule.</li><li>Qualified candidates outside the local area will also be considered for a work from home schedule. You must have high-speed internet (non-satellite) and a private home office to work from home.</li><li>Work hours are 8:00 a.m. to 4:30 p.m. CT, Monday through Friday.</li></ul>What You Will Do:<ul><li>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.</li><li>Educates internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc., in accordance with contractor guidelines.</li><li>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.</li></ul>To Qualify For This Position, You'll Need: <ul><li>Required Licenses and Certificates: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).</li><li>Required Education: Associate in a job-related field OR graduate of an Accredited School of Nursing.</li><li>Required Work Experience: Two years of clinical nursing experience.</li><li>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.</li><li>Required Software and Tools: Microsoft Office.</li></ul>We Prefer That You Have: <ul><li>Five years of clinical experience as a Registered Nurse, including two years in the following specialty area(s): Outpatient Surgical, Pain Management, Cosmetic Surgery, Prior Authorization, Medical Review, Medicare Part A, or Utilization Management.</li><li>Ability to work with multiple Windows-based programs simultaneously.</li><li>Intermediate Word, Excel, and Outlook skills.</li></ul>Our Comprehensive Benefits Package Includes:We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment. <ul><li>Subsidized health plans, dental and vision coverage</li><li>401k retirement savings plan with company match</li><li>Life Insurance</li><li>Paid Time Off (PTO)</li><li>On-site cafeterias and fitness centers in major locations</li><li>Education Assistance</li><li>Service Recognition</li><li>National discounts to movies, theaters, zoos, theme parks and more</li></ul>What We Can Do for You: We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.What To Expect Next: After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.Pay Range Information:Range Minimum  $ 47,263 Range Midpoint $ 68,905 Range Maximum  $ 90,548Pay Transparency Statement: Please note that this range represents the pay range for this and other positions that fall into this pay grade.  Compensation decisions within the range will be dependent upon a variety of factors, including experience, geographic location, and internal equity. </div></div></div></div></div></div></div></div></div></div>Equal Employment Opportunity StatementBlueCross BlueShield of South Carolina and our 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. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply 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.If you need special assistance or an accommodation while seeking employment, please email <a href="mailto:mycareer.help@bcbssc.com" target="_blank" rel="noopener noreferrer">mycareer.help@bcbssc.com</a> or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's <a href="https://www.southcarolinablues.com/web/public/resources/c4cb28a0-f717-4f26-8270-abae70243be7/Everify_EEO+2019.pdf?MOD=AJPERES&CVID=mKvY6R0" target="_blank" rel="noopener noreferrer">more information</a><a href="https://www.southcarolinablues.com/web/public/resources/c4cb28a0-f717-4f26-8270-abae70243be7/Everify_EEO+2019.pdf?MOD=AJPERES&CVID=mKvY6R0" target="_blank" rel="noopener noreferrer">.</a>Some states have required notifications. Here's <a href="https://www.southcarolinablues.com/web/public/resources/cf014797-0b05-46c2-ab33-ec3a1bf9864a/California+Notice+to+Applicants_.pdf?MOD=AJPERES&CVID=oJErh8p" target="_blank" rel="noopener noreferrer">more information</a>.

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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...