Clinical Nurse Auditor

Category: Analytics and Emerging Digital Technologies

Main location: United States, Georgia, Atlanta

Alternate Location(s): United States, North Carolina, Charlotte
United States, Tennessee, Knoxville

Position ID:J0726-2198

Employment Type: Full Time

Position Description:

CGI is seeking a Clinical Nurse Auditor to join our Clinical Services Group (CSG) Clinical Audit Team. In this role, you will conduct comprehensive clinical audits of medical records to determine the medical appropriateness and necessity of healthcare services provided to members of commercial and government health plans. Your expertise will support the identification of improper payments while ensuring audit decisions are objective, well-supported, and aligned with applicable clinical guidelines, regulatory requirements, and client-specific policies.

As a Clinical Nurse Auditor, you will leverage your critical thinking, clinical expertise, and strong documentation skills to review inpatient and outpatient claims, evaluate medical necessity, validate clinical services, and prepare detailed audit determinations. You will receive comprehensive training on CGI's audit methodologies, documentation standards, and proprietary tools while participating in ongoing education related to clinical procedures, disease states, regulatory changes, and audit best practices. This position is remote within the United States, and candidates must be available to work Eastern Time Zone business hours.

Your future duties and responsibilities:

Conduct inpatient and outpatient clinical audits to evaluate medical necessity, reasonable and necessary services, prior authorization validation, clinical validation, medical service charge audits, and other audit types as required

Review medical records and provider documentation to identify unsupported services and recover improper payments in accordance with client contracts and regulatory guidelines

Develop comprehensive audit rationales supported by clinical documentation, established review criteria, applicable regulations, and internal audit guidelines

Accurately document audit findings and determinations within CGI's audit platforms while maintaining thorough, well-organized case records

Collaborate with Physician Advisors and internal clinical specialists when required to support complex clinical determinations

Support Clinical Validation and DRG validation activities by documenting coding-related findings in partnership with specialized review teams

Maintain departmental productivity, quality, inter-rater reliability, and performance standards while meeting established deadlines

Communicate effectively with leadership regarding workload, scheduling, operational issues, and performance barriers while adhering to CGI corporate policies and compliance requirements

Required qualifications to be successful in this role:

Active, unrestricted Registered Nurse (RN) license in your state of residence

Minimum of 5 years of recent Intensive Care Unit (ICU) or Critical Care Unit (CCU) nursing experience

Strong clinical knowledge with the ability to evaluate complex medical records across multiple healthcare settings

Experience interpreting clinical documentation to support medical necessity and utilization review determinations

Excellent written communication skills with the ability to prepare detailed, well-supported clinical narratives using proper grammar and documentation standards

Strong proficiency with Microsoft Office applications including Outlook, Word, and Excel, along with Windows-based operating systems

Ability to work independently, manage multiple priorities, and consistently meet productivity and quality expectations

Strong critical thinking, analytical, and decision-making skills with exceptional attention to detail

Willingness to work Eastern Time Zone hours and travel up to 25% as needed for training or onsite audit activities

Desired qualifications

Previous experience performing medical record audits, utilization review, payment integrity, or clinical claim review

Experience reviewing Commercial and Government healthcare claims

Familiarity with medical necessity criteria, healthcare regulations, and payer audit processes

Experience with clinical documentation improvement (CDI), DRG validation, or payment integrity programs

Certified Professional Medical Auditor (CPMA), Certified Professional Coder (CPC), or other relevant healthcare certifications

Bachelor's degree in Nursing (BSN) or an advanced nursing degree

Other Information:
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, relevant training, and licensure and certifications. 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 $70,800.00 $123,800.00.
CGI's benefits are offered to eligible professionals on their first day of employment to include:
. Competitive compensation
. Comprehensive insurance options
. Matching contributions through the 401(k) plan and the share purchase plan
. Paid time off for vacation, holidays, and sick time
. Paid parental leave
.Learning opportunities and tuition assistance
. Wellness and Well being programs

Skills:

• Communication
• MS Office365