Nurse Auditor

Job description

Job Description

Nurse Auditor

Position Description
CGI Federal, a wholly owned subsidiary of CGI and industry leader in providing Clinical Audit Services to pubic and commercial healthcare insurance payers throughout the US, has opening in Ohio for Nurse Auditors. Working from a local CGI Federal office or from home, the primary function of Nurse Auditors is to review medical records and identify improper payments—overpayments and underpayments—particular as it pertains to medical necessity. Your future duties and responsibilities
- Review inpatient coding for potential errors, verify proper assignment and sequencing of ICD-9-CM diagnoses and procedure codes
- Identify any quality of care issues, validate medical necessity of inpatient admissions, as well as any procedures performed during the stays
- Assist in selection of inpatient cases for review, utilizing sound clinical judgment and coding knowledge
- Follow proper procedure for physician referral of all potential violations
- Enter review findings using Customized Audit System (CAS), providing rationale and references to support decisions
- Assist mentoring new staff members, work with IT staff to construct and refine edits as needed
- Work with support staff for scheduling and project coordination, utilize proper reference material for clinical decision-making, including Coding Manuals, Clinics and National and Local Coding Guidelines
- Assist in researching and developing new projects, travel for additional training and on-site reviews on an as-needed basis
- Meet weekly and monthly productivity standards along with acceptable physician referral rates, follow all related CGI Federal work guidelines and Code of Ethics, and assist Team Lead when needed. Required qualifications to be successful in this role
- Current RN Licensure, Knowledge of ICD-9-CM coding/DRG Assignment (APG/HCC/CPT/APR DRG/RUG is a plus)
-Previous clinical nursing experience (ER, Med-Surg a plus) and understanding the disease process and clinical treatment modalities, prefer knowledge of InterQual Clinical Decision Support Criteria
- Knowledge of Medicare/Medicaid criteria for inpatient admission, experience in medical record review (retrospective/inpatient a plus)
-Knowledge of healthcare reimbursement methodologies, working knowledge of computer applications/programs, including MS Outlook, Word and Excel, prefer Utilization Review and Case Management experience
- Must be independent, self-motivated and a critical thinker, able to operate with minimal supervision, meet deadlines and prioritize assignments. Positions may require up to 25% travel. 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.

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 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 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.

Skills

·  Analytical Thinking
·  Auditing (Claims)

Reference

595564