Remote Clinical Nurse Auditor

CGI•Atlanta, GA

3d•$52,200 - $114,900•Remote

About The Position

The Clinical Nurse Auditor is a vital member of the CGI CSG Clinical Audit Team. In this role, you will be responsible for reviewing medical records to determine the medical appropriateness of clinical services rendered to beneficiaries of various health plans, including Commercial and Government Clients, across a variety of care settings. The Clinical Nurse Auditor is charged with rendering independent, appropriate, well-supported, and thoroughly-documented decisions. These decisions may result in the identification of improper payments on paid claims on behalf of the Client from various Providers, including but not limited to acute care, outpatient, and other Provider types and care settings. You will be prepared for the role through a detailed, well-defined training process, gaining knowledge and skills in: Methods for reviewing medical records and provider documentation. The application of appropriate screening guidelines. The use of documentation formats tailored to Client requirements. Ongoing training and education are provided specific to audit processes, clinical procedures, disease states, and other topics. The review process may result in approval or denial of payment for previously-rendered services. Decisions are rendered through a well-defined process requiring the Auditor to incorporate clinical experience, knowledge, and critical thinking skills to assess available information. The Clinical Nurse Auditor reports to a Clinical Audit Team Leader, who provides support, feedback, and guidance. Audit performance review, Inter-Rater Reliability (IRR), and Performance Measurement (PM) are conducted through a comprehensive quality management program. Note: This position is remote-friendly (anywhere in the U.S.), provided candidates are willing to work Eastern Time Zone hours.

Requirements

Licensure: Registered Nurse (RN) with active, unrestricted licensure in the state of residence.
Clinical Experience: Five or more years of Intensive Care (ICU/CCU) nursing experience is required.
Technical Proficiency: Strong working knowledge of computer functions, Windows operating systems, and Microsoft Office (Outlook, Word, Excel).
Communication Skills: Ability to write well-reasoned reviews in a narrative style with accurate spelling, grammar, punctuation, and sentence structure.
Work Style: Ability to work independently, adapt to changing priorities, and meet strict productivity standards and deadlines.
Travel: Willingness to travel up to 25% for additional training and on-site reviews as needed.

Responsibilities

Conduct Claim Audits: Perform inpatient and outpatient audits to determine medical necessity, validate prior authorizations, conduct clinical validations, or execute medical service charge audits to recover improper payments.
Rationale Development: Develop clear rationale for audit decisions based on provider information, citing appropriate review guidelines and applicable regulations, and entering documentation into ProperPay.
Physician Referral: Follow designated procedures for referral to a Physician Advisor when required by Client contracts.
Clinical Validation: Document specified coding issues in conjunction with the DRG Validation Team as assigned.
Corporate Compliance: Follow CGI CSG policies, completing mandatory training, timesheets, payroll, and travel expense documents in a timely manner.
Team Communication: Communicate timely with the Team Lead regarding schedule changes, vacation requests, performance barriers, or technical issues.
Quality & Productivity: Comply with department standards regarding audit quality and productivity.
Other Duties: Perform additional tasks as assigned.