Therapy Clinical Reviewer (Master-level OT/PT) - CGS

CGS Administrators LLC
life insurance, paid holidays, tuition assistance, 401(k), remote work
United States, Tennessee, Nashville
2 Vantage Way (Show on map)
Mar 13, 2025
Summary This position is for an experienced, Master-level Physical or Occupational Therapist within our DME (Durable Medical Equipment) Medical Review Team. Perform reviews of prior authorization requests for DME to ensure medical necessity, request is within standard treatment for medical condition and provides a positive cost benefit for the member. This will be done by using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Document decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. To be successful, you will need to have clinical, critical thinking, time management and windows-based computer skills. The position will be computer based. Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we've been part of the national landscape, 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 that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! 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. Description Logistics: If you live within 40 miles of our Nashville, TN office, the position will be hybrid. For those living outside of the immediate Nashville area, the position will be fully remote. To work from home, you must have high-speed internet. Internet cannot be satellite based. You must also have a private home office space. This is a full-time position working with a base eight hours a day with a 30-minute lunch Monday through Friday. You can start your 8.5 hour day between 7:00 am to 10:00 am ET and conclude your day by 6:30 pm ET. Position is computer-based with minimal (if any) travel required. What You Will Do: 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, and 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. Documents medical rationale to justify payment or denial of services and/or supplies. Educates internal/external staff regarding medical review of therapy services, 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 RN 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. What You Need to Qualify: Required Education: Master's in a job related field. Required Work Experience: Two years clinical plus one year utilization/medical review, quality assurance, Inpatient Rehab Facility, Comprehensive Outpatient Rehab Facility or home health, OR 3 years clinical. Required Licenses and Certificates: Active, unrestricted PT, OT or SLP licensure from the United States and in the state of hire. What We Prefer You Have: 3 years clinical PT or OT experience, strongly preferred. Strong windows-based computer skills with the ability to move between windows-based software programs. Microsoft Office knowledge and intermediate Word and Excel skills. Critical thinking and clinical skills. Ability to manage time and priorities well with limited supervision. 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 access and opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company. Our comprehensive benefits package includes: 401(k) retirement savings plan with company match Fantastic 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 a healthy lifestyle premium discount Tuition assistance Service recognition 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. Management will be conducting interviews with the most qualified candidates. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Some states have required notifications. Here's more information. Equal Employment Opportunity Statement BlueCross 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 minorities, females, disabled individuals and 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 physical and mental disabilities. If you need special assistance or an accommodation while seeking employment, please e-mail mycareer.help@bcbssc.com or call 1-800-288-2227, 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.