Payment Integrity Edits Manager

Dallas, TX

Payment Integrity Edits Manager

Category: Analytics and Emerging Digital Technologies

Main location: United States, Texas, Dallas

Position ID: J0324-1896

Employment Type: Full Time

Position Description:

The Payment Integrity Edits Manager is a member of the CGI Payment Integrity Department, with responsibility over the edits life cycle, including development and maintenance of an edits management process. This role will be client-facing, supporting business development and client delivery as a subject matter expert regarding edits development and management.

The Payment Integrity Edits Manager has a sound knowledge base in edit research and development in pre- and post-payment medical claims auditing in conjunction with maintaining a robust quality assurance program. Edits are developed through a well-defined process which requires the Edits Manager to incorporate clinical experience, knowledge, and critical thinking skills to assess available information and render recommendations to create and update edit concepts which, when implemented, may result in identification of improper payments on paid claims on behalf insurers (Clients). Research may include reimbursement regulations, payment guidelines, healthcare provider contracts, and health insurance industry guidance. The position reports to the Director Delivery Services.

Your future duties and responsibilities:

• Work closely with Artificial Intelligence teams to further streamline the edit development processes.

• Maintaining quality assurance on all edits to ensure consistency across test and production environments, necessary updates are made based on changing regulations and policies, and tracking of client customized edits.

• Develops successful edit scenarios for all provider types

• Ensures that all edit development activities are conducted within the time frame stipulated by client contracts and service level agreements.

• Works with Audit Team leaders and team members to provide meaningful insights, timely feedback, and recommendations for Edit development.

• Serves as a technical subject matter expert for development of marketing materials.

• Aids with business development, including attending prospective client meetings as required.

• Develops and issues client-specific reports on edit development in an accurate and timely fashion.

• Works with the internal ProperPay developers to test and create edits within ProperPay.

• Effectively responds to issues and concerns raised by internal and external clients.

• Participates in and supports new client projects as required.

• Attend internal and external client meetings as required.

• Provides meaningful and timely feedback to the Edit and audit teams to improve the quality of audit and appeal determinations.

• Contributes to solution strategies and roadmaps for product and process improvements.

• Ensure high quality deliverables on schedule and within budget.

• Performs other duties as assigned.

Required qualifications to be successful in this role:

The Payment Integrity Edits Manager 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 or RHIA/RHIT/CCS certified through the American Health Information Management Association.

Previous pre-pay or post-payment auditing and edit development experience required (Minimum 5 years).

Must have strong understanding of edit development from both a pre- and post-payment perspective for both complex and automated reviews.

Health plan payer or health system experience (5 years minimum) in a payment integrity or revenue integrity related role required.

Development of a quality assurance process preferred.

Has strong working knowledge of CMS, Medicaid and Commercial (payer) reimbursement methods and systems and guidelines and payment methodologies.

Must have good working knowledge and experience of the different types of payment structures (fee schedule, POC, etc.) and how those can influence recovery opportunities.

Professional, organized and able to communicate effectively.

Professional appearance and demeanor; proven ability to work with individuals at all levels, including physicians, attorneys and senior level client staff.

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.

May be required to travel as much as 25% of the time for additional training, on-site reviews, and client consulting on an as-needed basis.

Minimum Education Required

Associates Degree (RHIT); Bachelors degree preferred and at least one of the following professional certifications: CCS-P, CPC, CPC-H/COC

*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 and training; and licensure and certifications. 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 is $53,100 -$139,300.

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.

#LI-KB5

Skills:

  • Certified Procedural Coder-US

  • Health Care Payers

What you can expect from us:

Together, as owners, let’s turn meaningful insights into action.

Life at CGI is rooted in ownership, teamwork, respect and belonging. Here, you’ll reach your full potential because…

You are invited to be an owner from day 1 as we work together to bring our Dream to life. That’s why we call ourselves CGI Partners rather than employees. We benefit from our collective success and actively shape our company’s strategy and direction.

Your work creates value. You’ll develop innovative solutions and build relationships with teammates and clients while accessing global capabilities to scale your ideas, embrace new opportunities, and benefit from expansive industry and technology expertise.

You’ll shape your career by joining a company built to grow and last. You’ll be supported by leaders who care about your health and well-being and provide you with opportunities to deepen your skills and broaden your horizons.

Come join our team—one of the largest IT and business consulting services firms in the world.

Qualified applicants will receive consideration for employment without regard to their race, ethnicity, ancestry, color, sex, religion, creed, age, national origin, citizenship status, disability, 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! Clickhere (https://cgi-veterans.jobs/) 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.

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.