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.
, 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 January .
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 $.
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 • My Assistance Program & other wellness 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.
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