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Senior Payment Integrity Analyst - Claims Editing

Category: Business Analysis (functional and technical)

Main location: United States, Georgia, Atlanta

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

Position ID:J0926-1957

Employment Type: Full Time

Position Description:

CGI is seeking an experienced Senior Analyst, Edits to join our growing Payment Integrity team. In this role, you will help expand CGI's claims edits library by identifying, developing, implementing, and optimizing edits designed to prevent inaccurate, inappropriate, or wasteful healthcare payments.

You will contribute across the full edit development lifecycle-from analyzing claims data and identifying opportunities to translating medical and coding policy into actionable edit logic, validating and testing new concepts, monitoring performance, and continuously optimizing results.

The ideal candidate combines hands-on claims edit development experience with strong healthcare coding and payment integrity expertise. You should be comfortable interpreting complex coding and reimbursement policies, translating them into clearly defined business rules, and collaborating with clinical, technical, and operational teams to bring new edit concepts into production.

This is an opportunity to directly influence payment accuracy while helping build and strengthen CGI's Payment Integrity capabilities.

Your future duties and responsibilities:

Claims Edit Development & Implementation

Identify high-impact edit opportunities through claims analysis, coding research, payment policy review, and emerging billing trends.

Research, design, build, and maintain professional and outpatient claims edit concepts.

Translate CMS requirements, medical policies, coding guidance, and industry standards into actionable edit logic.

Develop detailed rule specifications, including conditions, exclusions, thresholds, modifiers, and other decision criteria.

Create validation scenarios and datasets and support user acceptance testing (UAT) prior to deployment.

Partner with technical teams to ensure edit requirements are accurately implemented within claims rules engines.

Edit Performance & Optimization

Monitor edit performance, including yield, savings, false-positive rates, provider impact, and return on investment.

Analyze results and refine edit logic based on performance, coding changes, regulatory updates, and provider billing behavior.

Maintain an organized inventory of active edits, including specifications, supporting documentation, version history, and performance results.

Identify outdated, duplicative, or low-value edits and recommend modification or retirement.

Coding, Policy & Clinical Alignment

Apply deep knowledge of CPT, HCPCS, ICD-10, NCCI/MUE, CMS guidance, LCD/NCD requirements, and payer reimbursement policies to edit development.

Collaborate with Medical Directors, coding professionals, clinical auditors, and other subject matter experts to validate clinical and coding appropriateness.

Maintain awareness of regulatory and coding changes that may create new edit opportunities or require updates to existing logic.

Ensure edit concepts and supporting documentation meet applicable regulatory, compliance, and audit requirements.

Cross-Functional Collaboration

Partner with Payment Integrity, SIU, coding, claims operations, medical policy, analytics, provider relations, and technology teams.

Clearly communicate edit concepts, business logic, expected impact, and performance results to technical and non-technical stakeholders.

Support research and resolution of provider questions or disputes related to edit logic.

Contribute to reporting and dashboards that communicate edit performance, savings opportunities, and program outcomes.

Required qualifications to be successful in this role:

5+ years of relevant experience in payment integrity, claims edit development, claims analytics, medical/coding policy, healthcare reimbursement, or a closely related discipline.

Demonstrated hands-on experience developing, maintaining, or implementing pre-pay claims edits and/or post-pay audit logic.

Strong knowledge of CPT, HCPCS, ICD-10, NCCI/MUE, CMS reimbursement requirements, and professional/outpatient claims.

Experience translating coding, medical, or reimbursement policy into clearly defined claims rules or edit specifications.

Active professional coding certification such as CPC, CCS, COC, CPMA, RHIA, or RHIT.

Strong analytical and critical-thinking skills with the ability to investigate complex claims and reimbursement scenarios.

Strong written communication and documentation skills.

Ability to effectively manage multiple priorities and collaborate across clinical, business, technical, and operational teams.

Bachelor's degree in healthcare, business, data analytics, public health, or a related discipline, or equivalent combination of education and relevant experience.

Desired Qualifications

Hands-on edit development or payment policy experience involving one or more of the following:
Durable Medical Equipment (DME)
Home Infusion
High-Cost Drugs / Specialty Pharmacy
Therapy & Rehabilitation
Behavioral Health
Other professional or outpatient coding specialties
Experience with claims editing or rules platforms such as Optum/CES, ClaimsXten/Lyric, Cotiviti, McKesson, or comparable rules engines.
Experience using claims data and analytics to identify edit opportunities, payment leakage, trends, or potential savings.
Working knowledge of SQL and/or reporting and visualization tools.
Experience with Medicare, Medicaid, and commercial payer policies.
Clinical licensure, such as RN, is a plus.

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 $56,600.00 $132,100.00.
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:

• Analytical Thinking
• Regulatory project management