CGS Administrators, LLC

• Supports operations in the form of case review on both medical and regulatory matters. • Develops claim adjudication criteria for situations requiring medical judgment. • Provides input on issues and operational policies, processes, and procedures. • Educates staff and medical community on various aspects of medical policy and program administration. • May develop and update medical policy in consultation with appropriate regulatory personnel, medical consultants, and professional societies. • Develops external relationships with the medical community and serves as liaison between these entities and the contractors. • Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization. • Conducts research into new or controversial medical procedures and technology.

Role Description Provides prompt, accurate, thorough and courteous responses to all customer inquiries. Performs research as needed to resolve inquiries. This position is a full-time remote position (40-hours/week). The work hours are Monday-Friday 7:30AM-4PM CT. What You’ll Do: - Ensure effective customer relations by responding accurately, timely and courteously to telephone, written, web, or walk-in inquiries. - Accurately documents inquiries. - Initiate or process adjustments or performs other research as needed to resolve inquiries. - Coordinates with other departments to resolve problems. - Responds to, researches and/or assists with priority inquiries and special projects as required by management. - Provide feedback to management regarding customer problems, questions, and needs. - Maintains accurate records on complaints and/or other customer comments and makes recommendations for changes to management. - Follows through on complaints until resolved or reports to management as needed. - Maintain basic knowledge of quality work instructions and company policies. - Assists with process improvements through the recommendation of changes in procedures and techniques discovered during daily operations. - Maintains all departmental productivity, quality, and timeliness standards. - Identify and promptly reports and/or refers suspected fraudulent activities and system errors to the appropriate departments. Qualifications - High School Diploma or equivalent - Excellent verbal and written communication skills. - Strong human relations and organizational skills. - Ability to handle high stress situations. - Good judgment skills. - Strong customer service skills. - Ability to learn and operate multiple computer systems effectively and efficiently. - Basic computer operating skills. - Standard office equipment. Requirements - Associate degree (preferred) - 2 years of customer service or call center experience (preferred) - Knowledge of word processing, spreadsheet, and database software (preferred) 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 - Education Assistance - Service Recognition - National discounts to movies, theaters, zoos, theme parks and more

Role Description Provides supervision and direction of the statistical reporting function and data analysis to support clinical reporting function. - Monitors adherence to statistical reporting requirements, updates systems as necessary. - Sets and maintains general direction/focus of statistical reporting function. - Performs analysis and reporting including clinical trend analysis. - Develops reports through various data reporting tools. - Develops data-driven solutions to improve outcomes. - Collaborates with other areas to reduce expense through data analysis, including gathering business requirements, documentation, testing, and delivery of reporting. - Serves as internal subject matter expert and point of contact for query/design for clinical analysis. - Identifies data analysis needs based on customer. - Supervises staff including directing work, addressing performance, and providing training. - Reviews work and coaches subordinates. Qualifications - Associate's degree - 5 years of experience in healthcare data analysis and data retrieval. - Strong written and verbal communication skills. - Strong analytical, judgment, presentation, critical thinking, organizational and planning skills. - Working knowledge of statistical concepts, population statistical and analysis methods. - Comprehensive understanding of statistical principles and practices. - Strong decision-making, reasoning and mathematical skills. - Effectively direct and coordinate multiple tasks. - Able to effectively manage complex projects incorporating participation from key personnel across various areas of the company. - Basic knowledge of accounting principles. Requirements - Proven experience with database query/reporting tools, software and other applications, such as Access Databases, DB2, SQL, and Easytrieve. - Strong understanding of relational database structures, theories, principles, and practices with exposure to the analysis of relational database software and data retrieval methodologies. Benefits - Subsidized health plans, dental and vision coverage - 401K retirement savings plan with company match - Life Insurance - Paid Time Off (PTO) - Nine paid holidays - On-site cafeterias and fitness centers in major locations - Wellness program and healthy lifestyle premium discount - Tuition assistance - Service recognition - Employee Assistance - Discounts to movies, theaters, zoos, theme parks and more

Role Description We are currently hiring for an Appeals Specialist to join BlueCross BlueShield of South Carolina. In this role as Appeals Specialist, you will be required to perform non-medical reviews and process redetermination letters. Logistics: - CGS (cgsadmin.com) – one of BlueCross BlueShield's South Carolina subsidiary companies. - This position is onsite with work hours starting between 6:00 AM and 7:30 AM Central Time. You will work an 8-hour shift schedule. - It may be necessary, given the business need, to work occasional overtime. - This role is fully remote or can sit onsite at 26 Century Blvd, Suite ST610 Nashville, TN 37214 United States of America. - As a Service Contract Act (SCA) employee, you are required to enroll in our health insurance, even if you already have other health insurance. - Your coverage begins on the first day of the month following 28 days of full-time employment. What You’ll Do: - Performs non-medical reviews and processes redetermination letters ensuring timeliness and accuracy. - Prepares unit reports, analyzes and interprets workload, and processes issues utilizing various software tools. - Updates letters and documents within the department when necessary. - May gather and prepare documentation for legal inquiries and administrative requests. Qualifications - High School Diploma or equivalent. - 2 years job related field experience. - Demonstrated proficiency in word processing and spreadsheet software. - Excellent organizational, customer service, and written and verbal communication skills. - Good judgment skills. - Proficiency in spelling, punctuation, and grammar skills. - Microsoft Office proficiency. Requirements - Experience in medical claims processing, appeals, or coding strongly preferred. - Medicare Part B experience preferred. - Strong computer proficiency, with the ability to navigate multiple systems and work across dual screens efficiently. - Intermediate-level Excel skills. - Experience creating letters and documents by reviewing appeals and extracting information with a high degree of accuracy; updates departmental documents as needed. 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. - Education Assistance. - Service Recognition. - National discounts to movies, theaters, zoos, theme parks, and more.

• Conducts internal and/or external timely operational, financial, and/or compliance audits of divisions, departments, providers, and activities of the corporation • Identifies, documents, and evaluates business risks • Develops written audit programs • Conducts testing and analysis of existing controls to determine adequacy and effectiveness • Prepares written work papers to document testing results and conclusions reached • Documents issues, the causes of those issues, and their effects on the process/function and the corporation • Serves as Lead Auditor on more complex audit assignments • Drafts recommendations to limit risks and improve processes, functions and activities • Writes audit reports for corporate executive management • Collects and analyzes data to detect deficient controls, duplicated effort, fraud, or non-compliance with laws • Conducts testing of corrective actions as identified • Develops detailed reports on each audit conducted • Prepares reports of findings and recommendations for management • Provides training to and assists or leads other auditors in completing their assignments

Role Description Provides prompt, accurate, thorough and courteous responses to all customer inquiries. Inquiries may be non-routine and require deviation from standard screens, scripts, and procedures. Performs research as needed to resolve inquiries. - 60% Ensures effective customer relations by responding accurately, timely, and courteously to telephone, written, web, or walk-in inquiries. Handles situations which may require adaptation of response or extensive research. Accurately documents inquiries. - 15% Initiates or processes adjustments or performs other research as needed to resolve inquiries. Coordinates with other departments to resolve inquiries. Researches, responds to, and/or assists with priority inquiries and special projects as required by management. - 10% Provides feedback to management regarding customer problems, questions and needs. Maintains accurate records on complaints and/or other customer comments, and makes recommendations for changes to management. Follows through on inquiries until resolved or reports to management as needed. - 10% Maintains basic knowledge of quality work instructions and company policies. Assists with process improvements through the recommendation of changes in procedures and techniques discovered during daily operations. Maintains all departmental productivity, quality, and timeliness standards. - 5% Assist with the training of new employees and cross training of coworkers. Qualifications - Required Education: High School Diploma or equivalent - Required Work Experience: 1 year of claims processing or customer service experience OR Bachelor's Degree in lieu of work experience. - Required Skills and Abilities: - Excellent verbal and written communication skills. - Proficient spelling, punctuation, and grammar. - Strong human relations and organizational skills. - Ability to handle high stress situations. - Good judgment. - Ability to handle confidential or sensitive information with discretion. - Ability to learn and operate multiple computer systems effectively and efficiently. - Required Software and Tools: Basic computer operating skills. Standard office equipment. - Preferred Education: Associate Degree - Preferred Work Experience: 3 years of customer service or call center experience. - Preferred Software and Other Tools: Knowledge of word processing, spreadsheet, and database software. Work Environment - Typical office environment. 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 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 mycareer.help@bcbssc.com 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.

• Research the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests. • Provide thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines. • Document decisions within mandated timeframes and in compliance with applicable regulations or standards. • Perform thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements, governing agencies, policies and procedures, while adhering to confidentiality regulations regarding protected health information. • Perform appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and or application to benefit or policy provisions. • Perform special projects including reviews of clinical information to identify quality of care issues.

Summary Provides prompt, accurate, thorough and courteous responses to all customer inquiries. Performs research as needed to resolve inquiries. Description Logistics: CGS - One of BlueCross BlueShield's South Carolina subsidiary companies. Location: This position is full-time (40 hours/week) Monday-Friday. This is a remote position with training from 7:30am-4pm CST for six weeks. Normal work hours will be from 8:30-5pm CST What You’ll Do: - Ensure effective customer relations by responding accurately, timely and courteously to telephone, written, web, or walk-in inquiries. Accurately documents inquiries. - Initiate or processes adjustments or perform other research as needed to resolve inquiries. Coordinates with other departments to resolve problems. Responds to, research and/or assists with priority inquiries and special projects as required by management. - Provide feedback to management regarding customer problems, questions and needs. Maintains accurate records on complaints and/or other customer comments and makes recommendations for changes to management. Follows through on complaints until resolved or reports to management as needed. - Maintain basic knowledge of quality work instructions and company policies. Assists with process improvements through the recommendation of changes in procedures and techniques discovered during daily operations. Maintains all departmental productivity, quality, and timeliness standards. - Identify and promptly report and/or refer suspected fraudulent activities and system errors to the appropriate departments. To Qualify For This Position, You'll Need The Following: - Required Education: High School Diploma or equivalent - Required Skills and Abilities: Excellent verbal and written communication skills. Strong human relations and organizational skills. Ability to handle high stress situations. Good judgment skills. Strong customer service skills. Ability to learn and operate multiple computer systems effectively and efficiently. - Required Software and Other Tools: Basic computer operating skills. Standard office equipment. We Prefer You Have: - Preferred Education: Associate Degree - Preferred Work Experience: 2 years-of customer service or call center experience. - Preferred Software and Other Tools: Knowledge of word processing, spreadsheet, and database software. Our Comprehensive Benefits Package Includes The Following: 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. - 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 - Education Assistance - Service Recognition - National discounts to movies, theaters, zoos, theme parks and more 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. 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 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 mycareer.help@bcbssc.com 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 more information. Some states have required notifications. Here's more information.

Summary We are currently hiring for an Appeals Analyst to join BlueCross BlueShield of South Carolina. In this role as Appeals Analyst, you will research the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests. Additionally, you will provide thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines. Lastly, you will document decisions within mandated timeframes and in compliance with applicable regulations or standards. 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. Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future. Description Logistics CGS –one of BlueCross BlueShield's South Carolina subsidiary companies. This position is full time (40 hours/week) Monday-Friday 8:00-4:30PM CST and will be W@H OR On-site at One Century Plaza, Nashville TN. What You Will Do: - Documents the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards. - Performs thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements, governing agencies, policies and procedures, while adhering to confidentiality regulations regarding protected health information. - Performs appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and or application to benefit or policy provisions. - Performs special projects including reviews of clinical information to identify quality of care issues. To Qualify for This Position, You Will Need: - Associate's in a job-related field - Graduate of Accredited School of Nursing - 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, OR, 3 years clinical. FOR PALMETTO GBA (CO. 033) ONLY: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience or a combination of experience in clinical, utilization/medical review, quality assurance or home health experience totaling four years. - Working knowledge of word processing software. - Ability to work independently, prioritize effectively, and make sound decisions. - Working knowledge of managed care and various forms of health care delivery systems. - Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience. - Knowledge of specific criteria/protocol sets and the use of the same. - Good judgment skills. - Demonstrated customer service, organizational, oral and written communication skills. - Ability to persuade, negotiate, or influence others. - Analytical or critical thinking skills. - Ability to handle confidential or sensitive information with discretion. - Microsoft Office. - Required License and Certificate: An active, unrestricted RN license 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). What We Prefer You Have: - Utilization Review / Medical Review experience. - MCS System Knowledge. - Medicare Part B. - CMS Knowledge. - Knowledge of claims systems. - Ability to effectively use Microsoft Office applications, such as Word, Power point and Excel. - Coding experience. What We Can Do for You: - 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. 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 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 mycareer.help@bcbssc.com 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 more information. Some states have required notifications. Here's more information.

• Documents the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards. • Performs thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements, governing agencies, policies and procedures, while adhering to confidentiality regulations regarding protected health information. • Performs appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and or application to benefit or policy provisions. • Performs special projects including reviews of clinical information to identify quality of care issues.