Senior Analyst, Edits | Payment Integrity (Remote)

About the role

CGI is seeking a results-oriented Senior Analyst to join our growing Edits team. In this pivotal role, you will be responsible for expansively growing CGI’s edits library and driving measurable value by identifying and preventing improper payments.

Responsibilities

• Edit Development & Implementation
• Identify Opportunities: Use claim data analysis to pinpoint high-impact edit opportunities.
• Translate Policy: Convert medical policy, CMS rules, and coding guidance into actionable logic.
• Technical Design: Create detailed rule specifications, including conditions, exclusions, thresholds, and flags.
• Validation: Design validation datasets and lead rigorous pre-deployment user acceptance testing (UAT).
• Monitoring & Optimization
• Performance Tracking: Monitor yield, false positives, ROI, and provider abrasion.
• Continuous Improvement: Refine edits based on real-world results, coding updates, and provider behavior.
• Lifecycle Management: Maintain a documented inventory of active edits and retire obsolete or low-value rules.
• Clinical & Coding Alignment Validation
• Partner with Medical Directors and internal auditors (RNs/Coders) to ensure clinical appropriateness.
• Compliance: Ensure all edits strictly comply with CMS coding policies, NCCI, and LCD/NCD rules.
• Stakeholder Engagement
• Partner with SIU, claims operations, and policy teams to align on strategy.
• Communication: Present edit design rationale and performance dashboards to leadership.

Requirements

• Certifications (Must-Have): Active coding certification (CCS or CPC) with deep clinical coding expertise.
• Professional Experience: 5+ years in payment integrity, claims analytics, medical policy, or coding.
• Technical Knowledge: Deep expertise in CPT/HCPCS, ICD-10, DRG, APC/OPPS, and NCCI bundling policies.
• Domain Expertise: Proven experience in prepay editing or post-pay audit logic.
• Education: Bachelor’s degree in Business, Healthcare, Data Analytics, Public Health, or a related field (or equivalent experience).

Preferred Skills

• Technical Tools: Proficiency in SQL and experience with claims rules platforms (e.g., Optum/CES, Cotiviti, McKesson).
• Clinical Background: Current RN licensure.

Other Information

To support the ability to reward for merit-based performance, 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 for this role in the U.S. is $75,000.00 - $100,000.00.