Clinical Nurse Auditor
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Clinical Nurse Auditor (ICU experience) - Remote
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.
• This position can be located remotely anywhere in the U.S, and candidates must be willing to work in Eastern Time Zone hours.
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
• The Clinical Nurse Auditor is a Registered Nurse with active, unrestricted licensure through the Board or Agency charged with providing such licensure in the Auditor's state of residence.
• Intensive Care nursing experience of five or more years is required.
• 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
Post Payment Claims Auditing
5 years
ICU/CCU Nursing experience
5-10 years
CGI anticipates accepting applications for this position through November 30, 2024.
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
*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 $60,300 -$118,700.
At CGI we call our professionals 'CGI Partners' 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:
CGI's benefits are offered to eligible professionals on their first day of employment to include:
• Competitive compensation including profit participation program
• Comprehensive medical, dental, and vision benefits
• Basic life and accidental death & dismemberment insurance
• Matching contributions through 401(k) plan, and CGI share purchase plan
• Flexibility and paid accrued vacation leave, ranging from 10 to 20 days per year, based on job level, years of relevant prior experience, and years of service
• 10 paid holidays per year
• At least 80 consecutive hours of paid sick/safe leave (except where applicable state/local law requires more)
• Paid parental leave, ranging from 20 to 70 consecutive business days based on circumstances of leave and applicable laws
• Bereavement leave, ranging from 1 to 7 days per year based on relationship.
• Paid jury duty leave, up to time summoned
• Learning opportunities and tuition assistance
• Wellness and Well-being programs
For more detailed information about our benefits offerings visit Benefits | CGI Careers
Please note that the benefits listed above are subject to change based on the specific terms and conditions of the contract being supported.
#CSG-TMC-F24
#LI-KB5
Together, as owners, let's turn meaningful insights into action.
Life at CGI is rooted in ownership, teamwork, respect and belonging. Here, you'll reach your full potential because...
You are invited to be an owner from day 1 as we work together to bring our Dream to life. That's why we call ourselves CGI Partners rather than employees. We benefit from our collective success and actively shape our company's strategy and direction.
Your work creates value. You'll develop innovative solutions and build relationships with teammates and clients while accessing global capabilities to scale your ideas, embrace new opportunities, and benefit from expansive industry and technology expertise.
You'll shape your career by joining a company built to grow and last. You'll be supported by leaders who care about your health and well-being and provide you with opportunities to deepen your skills and broaden your horizons.
Come join our team-one of the largest IT and business consulting services firms in the world.
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, height, weight, 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 Position ID 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 Position ID will not be returned.
We make it easy to translate military experience and skills! Click here to be directed to our site that is dedicated to veterans and transitioning service members.
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. Dependent upon role and/or federal government security clearance requirements, and in accordance with applicable laws, some background investigations may include a credit check. 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.
About the job
Clinical Nurse Auditor
To see similar active jobs please follow this link: Remote Finance jobs
Clinical Nurse Auditor (ICU experience) - Remote
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.
• This position can be located remotely anywhere in the U.S, and candidates must be willing to work in Eastern Time Zone hours.
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
• The Clinical Nurse Auditor is a Registered Nurse with active, unrestricted licensure through the Board or Agency charged with providing such licensure in the Auditor's state of residence.
• Intensive Care nursing experience of five or more years is required.
• 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
Post Payment Claims Auditing
5 years
ICU/CCU Nursing experience
5-10 years
CGI anticipates accepting applications for this position through November 30, 2024.
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
*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 $60,300 -$118,700.
At CGI we call our professionals 'CGI Partners' 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:
CGI's benefits are offered to eligible professionals on their first day of employment to include:
• Competitive compensation including profit participation program
• Comprehensive medical, dental, and vision benefits
• Basic life and accidental death & dismemberment insurance
• Matching contributions through 401(k) plan, and CGI share purchase plan
• Flexibility and paid accrued vacation leave, ranging from 10 to 20 days per year, based on job level, years of relevant prior experience, and years of service
• 10 paid holidays per year
• At least 80 consecutive hours of paid sick/safe leave (except where applicable state/local law requires more)
• Paid parental leave, ranging from 20 to 70 consecutive business days based on circumstances of leave and applicable laws
• Bereavement leave, ranging from 1 to 7 days per year based on relationship.
• Paid jury duty leave, up to time summoned
• Learning opportunities and tuition assistance
• Wellness and Well-being programs
For more detailed information about our benefits offerings visit Benefits | CGI Careers
Please note that the benefits listed above are subject to change based on the specific terms and conditions of the contract being supported.
#CSG-TMC-F24
#LI-KB5
Together, as owners, let's turn meaningful insights into action.
Life at CGI is rooted in ownership, teamwork, respect and belonging. Here, you'll reach your full potential because...
You are invited to be an owner from day 1 as we work together to bring our Dream to life. That's why we call ourselves CGI Partners rather than employees. We benefit from our collective success and actively shape our company's strategy and direction.
Your work creates value. You'll develop innovative solutions and build relationships with teammates and clients while accessing global capabilities to scale your ideas, embrace new opportunities, and benefit from expansive industry and technology expertise.
You'll shape your career by joining a company built to grow and last. You'll be supported by leaders who care about your health and well-being and provide you with opportunities to deepen your skills and broaden your horizons.
Come join our team-one of the largest IT and business consulting services firms in the world.
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, height, weight, 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 Position ID 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 Position ID will not be returned.
We make it easy to translate military experience and skills! Click here to be directed to our site that is dedicated to veterans and transitioning service members.
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. Dependent upon role and/or federal government security clearance requirements, and in accordance with applicable laws, some background investigations may include a credit check. 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.