Senior Payment Integrity Analyst – Claims Editing

CGI is seeking an experienced Senior Analyst Edits to join our growing Payment Integrity this role you will help expand CGIs 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 lifecyclefrom 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 CGIs Payment Integrity capabilities.

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Identify outdated duplicative or low-value edits and recommend modification or retirement.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

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.

Bachelors 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 $56600.00 $132100.00.
CGIs 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

• Analytical Thinking
• Regulatory project management

Together as owners lets turn meaningful insights into action.

Life at CGI is rooted in ownership teamwork respect and belonging. Here youll 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. Thats why we call ourselves CGI Partners rather than employees. We benefit from our collective success and actively shape our companys strategy and direction.

Your work creates value. Youll 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.

Youll shape your career by joining a company built to grow and last. Youll 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 teamone 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 pregnancy medical condition military and veteran status marital status sexual orientation or perceived sexual orientation gender gender identity and gender expression familial status or responsibilities reproductive health decisions political affiliation genetic information height weight or any other legally protected status or characteristics to the extent required by applicable federal state and/or local laws where we do business.

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 . You will need to reference the Position ID 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 Position ID 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. Dependent upon role and/or federal government security clearance requirements and in accordance with applicable laws some background investigations may include a credit check. CGI will consider for employment qualified applicants with arrests and conviction records in accordance with all local regulations and ordinances.

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 CGIs legal duty to furnish information.