Senior Analyst, Edits | Payment Integrity (Remote)

Category: Analytics and Emerging Digital Technologies

Main location: United States, Tennessee, Knoxville

Alternate Location(s): United States, Georgia, Atlanta
United States, North Carolina, Charlotte
United States, Virginia, Fairfax
United States, Texas, Dallas
United States, Texas, Houston

Position ID:J0126-0518

Employment Type: Full Time

Position Description:

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.

As a Senior Analyst, you will manage the full lifecycle of edit development-from initial opportunity identification to rules design, clinical validation, and deployment. You will serve as a subject matter expert, blending deep coding domain expertise with advanced analytics to ensure payment accuracy and integrity across the healthcare landscape.

Your future duties and responsibilities:

1. 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).

2. 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.

3. 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.

4. Cross-Functional Collaboration

Stakeholder Engagement: Partner with SIU, claims operations, and policy teams to align on strategy.

Communication: Present edit design rationale and performance dashboards to leadership.

Required qualifications to be successful in this role:

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:

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 $75,000.00 - $100,000.00.

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