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CGI Technologies and Solutions, Inc. Clinical Nurse Appeals Auditor in Cleveland, Ohio

Clinical Nurse Appeals Auditor

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Clinical Nurse Appeals Auditor

Category: Business Consulting, Strategy and Digital Transformation

City: Cleveland, Ohio, US United States

Position ID: J0621-1703

Employment Type: Full Time

Position Description:

The Clinical Nurse Appeals Auditor is a member of the CGI 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 Appeals 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 Appeals Auditor has a sound knowledge base in retrospective medical claims auditing; responsible for determining if the services billed support what is documented in the medical record. The appeal process may result in uphold, modification or reversal of previously worked audits. 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 Appeals Auditor reports to a Clinical Audit Appeals Team Leader/Manager, 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.

Your future duties and responsibilities:

• Conducts inpatient / outpatient claim audits at the appeal level to determine new information submitted meets original claim billed. Able to effective strengthen denials by using published resources, appropriate review guidelines, applicable regulations and/or internal review guidelines, which demonstrate that the medical record does not match the services billed.

• For Clinical Validation audits, collaborates with coder in providing specific documentation that address and strengthens denial.

• Strong writing skills required to effectively rebuttal denials that will withstand IRO reviews.

• Ability to defend clinical decision to client and providers when necessary.

• Follows CGI 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 Appeals Auditor is a Registered Nurse (RN) 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 a minimum of five (5) is required, 10 or more preferred; a minimum of three (3) or more years responding to appeals and denials in a post payment medical claims review or similar organization required. Must demonstrate critical clinical thinking skills and proven ability to write a well-reasoned review in narrative style, with accurate spelling, grammar, punctuation, and sentence structure.

Desired Skills:

Previous work experience as clinical documentation specialist (CDI) or utilization/case manager in an acute care setting (in addition to 5 years ICU experience) is desired.

Working knowledge of CMS and official coding guidelines and groupers desired.

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 Auditor must be able to work independently from home, 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. Must be willing to train in on-site facility for up to two weeks.

Minimum Education Required: Registered Nurse with up to date license; Bachelors degree in nursing preferred.

Est. Salary Range (Colorado Only): $66k-107kk

*Disclaimer: In accordance with Colorado’s Equal Pay for Equal Work Act, effective January 1, 2021, a good faith hourly or base salary range must be posted for all positions where the work may be performed in the state of Colorado. Therefore, this good faith salary range will only apply where this described position will be performed in the state, and should not be considered the compensation range in other locations or for other positions.

At CGI we call our professionals “members” 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:

• Competitive base salaries

• Eligibility to participate in an attractive Share Purchase Plan (SPP) in which the company matches dollar-for-dollar contributions made by eligible employees, up to a maximum, for their job category

• 401(k) Plan and Profit Participation for eligible members

• Generous holidays, vacation, and sick leave plans

• Comprehensive insurance plans that include, among other benefits, medical, dental, vision, life, disability, out-of-county emergency coverage in all countries of employment;

• Back-up child care, Pet insurance, a Member Assistance Program, a 529 college savings program, a personal financial management tool, lifestyle management programs and more

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Skills:

  • Communication (Oral/Written)

What you can expect from us:

Build your career with us.

It is an extraordinary time to be in business. As digital transformation continues to accelerate, CGI is at the center of this change—supporting our clients’ digital journeys and offering our professionals exciting career opportunities.

At CGI, our success comes from the talent and commitment of our professionals. As one team, we share the challenges and rewards that come from growing our company, which reinforces our culture of ownership. All of our professionals benefit from the value we collectively create.

Be part of building one of the largest independent technology and business services firms in the world.

Learn more about CGI at www.cgi.com .

No unsolicited agency referrals please.

CGI is an equal opportunity employer.

Qualified applicants will receive consideration for employment without regard to their race, ethnicity, ancestry, color, sex, religion, creed, age, national origin, citizenship status, disability, pregnancy, medical condition, military and veteran status, marital status, sexual orientation or perceived sexual orientation, gender, gender identity and gender expression, familial status, political affiliation, genetic information, or any other legally protected status or characteristics.

CGI provides reasonable accommodations to qualified individuals with disabilities. If you need an accommodation to apply for a job in the U.S., please email the CGI U.S. Employment Compliance mailbox at USEmploymentCompliance@cgi.com . You will need to reference the requisition number of the position in which you are interested. Your message will be routed to the appropriate recruiter who will assist you. Please note, this email address is only to be used for those individuals who need an accommodation to apply for a job. Emails for any other reason or those that do not include a requisition number will not be returned .

We make it easy to translate military experience and skills! Click here to be directed to our site that is dedicated to veterans and transitioning service members.

All CGI offers of employment in the U.S. are contingent upon the ability to successfully complete a background investigation. Background investigation components can vary dependent upon specific assignment and/or level of US government security clearance held. Qualified applicants with arrest and conviction records are welcome to apply.

CGI will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with CGI’s legal duty to furnish information.

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