Senior Payment Integrity Analyst - Claims Editing

• Create your profile | Sign in
• Activate career alerts

Find similar career opportunities

Senior Payment Integrity Analyst - Claims Editing

Category: Business Analysis (functional and technical)

Main location: United States, Georgia, Atlanta

Alternate Location(s): United States, North Carolina, Charlotte

United States, Tennessee, Knoxville

United States, Texas, Dallas

United States, Texas, Houston

Position ID: J0926-1957

Employment Type: Full Time

Position Description:

CGI is seeking an experienced Senior Analyst, Edits to join our growing Payment Integrity team. In this role, you will help expand CGI's 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 lifecycle-from 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 CGI's Payment Integrity capabilities.

Your future duties and responsibilities:

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.

Required qualifications to be successful in this role:

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.

Bachelor''s 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 $56,600.00 $132,100.00.

CGI''s 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

Skills:

• Analytical Thinking
• Regulatory project management

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, 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 US_Employment_Compliance@cgi.com. 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 CGI's legal duty to furnish information.

Have you been referred by a CGI Partner for this position? *

Yes No

CGI Partner's email (@cgi.com)*

First Name

Last Name

I agree to allow CGI to contact the CGI Partner who referred me to obtain additional information about my application and confirm my referral.*

• This field is required.

CGI is an Equal Opportunity Employer, to include disability and protected veteran status; we are committed to compliance with U.S. laws and regulations. Click here to access an overview of our U.S. Equal Employment Opportunity and Anti-Harassment Policy.

Applicants have rights under Federal Employment Laws:

• EPPA
• FMLA
• Know Your Rights: Workplace Discrimination is Illegal
• Pay Transparency Statement Policy

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 US_Employment_Compliance@cgi.com. 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.

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.