Clinical Nurse Auditor
Category: Analytics and Emerging Digital Technologies
Main location: United States, Texas, Dallas
Alternate Location(s): United States, Texas, Dallas
United States, Texas, Houston
United States, Texas, Austin
United States, Texas, San Antonio
United States, Arizona, Phoenix
United States, California, Los Angeles
United States, Colorado, Denver
United States, Connecticut, Hartford
United States, District of Columbia, Washington DC
United States, Georgia, Atlanta
United States, Illinois, Chicago
United States, Massachusetts, Boston
United States, New Jersey, Jersey City
United States, New York, New York City
United States, Ohio, Cleveland
United States, Pennsylvania, Pittsburg, Philadephia
United States, Virginia, Reston
Position ID:J1023-1420
Employment Type: Full Time
Position Description:
The Clinical Nurse Auditor is a member of the CGI CSG Clinical Audit Team, with responsibility for reviewing medical records to determine the medical appropriateness in a variety of care settings for clinical services rendered to beneficiaries of various health plans, including Commercial and Government Clients. The Clinical Nurse Auditor is charged with rendering independent, appropriate, well-supported, and thoroughly-documented decisions which may result in identification of improper payments on paid claims on behalf of the Client from various Providers of clinical services, including but not limited to acute care, outpatient and other Provider types and care settings. The Clinical Nurse Auditor is prepared for the role through a detailed, well-defined training process, gaining knowledge and skills in methods for review of the medical record and other provider documentation, application of appropriate screening guidelines, and use of the documentation format tailored to the Client’s requirements. Ongoing training and education are provided specific to audit processes, clinical procedures, disease states, and other topics as indicated. The review process may result in approval or denial of payment for previously-rendered services, and decisions are rendered through a well-defined process which requires the Auditor to incorporate clinical experience, knowledge, and critical thinking skills in order to assess available information and render a decision. The Clinical Nurse Auditor reports to a Clinical Audit Team Leader, who provides support, feedback, and guidance to the Auditor. Audit performance review, inter-rater reliability (IRR) and performance measurement (PM) are performed through a well-defined review and quality management program.
Your future duties and responsibilities:
• Conducts inpatient and outpatient claim audits to determine medical necessity/reasonable and necessary services, validation of prior authorization, clinical validation, medical service charge audit, or other audit types as required, thereby recovering improper payments when it is determined through the audit process that the medical record does not support the services billed. Other types of audits may be performed as required by the Client.
• Develops rationale for the audit decision based on the provider’s submitted information, citing appropriate review guidelines, applicable regulations and/or internal review guidelines, and enters clearly documented information in ProperPay. Follows the designated procedure for referral to a Physician Advisor if required by Client contract.
• For Clinical Validation audits, documents specified coding issues in conjunction with the DRG Validation Team as assigned.
• Follows CGI CSG policies and processes, completing mandatory training, timesheets, payroll, travel expense documents, and other corporate requirements in a timely manner.
• Communicates timely with Team Lead required regarding illness, appointments, vacation requests, changes in work schedule, performance barriers, and computer issues.
• Complies with department standards regarding productivity and audit quality.
Performs other duties as assigned.
Required qualifications to be successful in this role:
• 5 to 10 years ICU/CCU Nursing experience is must.
• Case management or chart auditing is a plus.
• The Clinical Nurse Auditor should be Registered Nurse with active, unrestricted licensure through the Board or Agency charged with providing such licensure in the Auditor’s state of residence.
• A strong working knowledge of computer functions, Microsoft Office (Outlook, Word, Excel) applications, and Windows operating systems is required in order to manage audit processes.
• The clinical nurse auditor utilizes skills to write a well-reasoned review in narrative style, with accurate spelling, grammar, punctuation, and sentence structure.
• The Auditor must be able to work independently, adapt to changing priorities, and meet department productivity standards and deadlines.
• The Auditor may be required to travel as much as 25% of the time for additional training and on-site reviews on an as-needed basis.
Skill set Years of experience Proficiency level
Post Payment Claims Auditing 5 years
ICU/CCU Nursing experience 5-10 years
Desired qualifications/non-essential skills required
Skill set Years of experience Proficiency level
Team-Oriented
Project-Oriented
Minimum Education Required: Bachelors Degree Nursing
*CGI is required by law in some jurisdictions to include a reasonable estimate of the compensation range for this role. The determination of this range includes various factors not limited to: skill set level; experience and training; and licensure and certifications. CGI typically does not hire individuals at or near the top of the range for their role. Compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range is $59,700 -$139,300.
At CGI we call our professionals “members” to reinforce that all who join our team are, as owners, empowered to participate in the challenges and rewards that come from building a world-class company. CGI’s benefits include:
Competitive base salaries
Eligibility to participate in an attractive Share Purchase Plan (SPP) in which the company matches dollar-for-dollar contributions made by eligible employees, up to a maximum, for their job category
401(k) Plan and Profit Participation for eligible members
Generous holidays, vacation, and sick leave plans
Comprehensive insurance plans that include, among other benefits, medical, dental, vision, life, disability, out-of-county emergency coverage in all countries of employment;
Back-up child care, Pet insurance, a Member Assistance Program, a 529 college savings program, a personal financial management tool, lifestyle management programs and more.
#LI- KB5
Skills:
- Project Management
What you can expect from us:
Insights you can act on
While technology is at the heart of our clients’ digital transformation, we understand that people are at the heart of business success.
When you join CGI, you become a trusted advisor, collaborating with colleagues and clients to bring forward actionable insights that deliver meaningful and sustainable outcomes. We call our employees “members” because they are CGI shareholders and owners and owners who enjoy working and growing together to build a company we are proud of. This has been our Dream since 1976, and it has brought us to where we are today – one of the world’s largest independent providers of IT and business consulting services.
At CGI, we recognize the richness that diversity brings. We strive to create a work culture where all belong and collaborate with clients in building more inclusive communities. As an equal-opportunity employer, we want to empower all our members to succeed and grow. If you require an accommodation at any point during the recruitment process, please let us know. We will be happy to assist.
Ready to become part of our success story? Join CGI – where your ideas and actions make a difference.
Qualified applicants will receive consideration for employment without regard to their race, ethnicity, ancestry, color, sex, religion, creed, age, national origin, citizenship status, disability, pregnancy, medical condition, military and veteran status, marital status, sexual orientation or perceived sexual orientation, gender, gender identity, and gender expression, familial status, political affiliation, genetic information, or any other legally protected status or characteristics.
CGI provides reasonable accommodations to qualified individuals with disabilities. If you need an accommodation to apply for a job in the U.S., please email the CGI U.S. Employment Compliance mailbox at US_Employment_Compliance@cgi.com. You will need to reference the requisition number of the position in which you are interested. Your message will be routed to the appropriate recruiter who will assist you. Please note, this email address is only to be used for those individuals who need an accommodation to apply for a job. Emails for any other reason or those that do not include a requisition number will not be returned.
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All CGI offers of employment in the U.S. are contingent upon the ability to successfully complete a background investigation. Background investigation components can vary dependent upon specific assignment and/or level of US government security clearance held. CGI will consider for employment qualified applicants with arrests and conviction records in accordance with all local regulations and ordinances.
CGI will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with CGI’s legal duty to furnish information.