Senior Payment Integrity Analyst – Claims Editing

Position Description

Senior Analyst, Edits

CGI is seeking a results oriented Senior Analyst to join our growing edits team. This role will be responsible for expansively growing CGI's edits library and driving value through the identification and prevention of improper payments.

The successful candidate will be responsible for designing, implementing, and managing edits that prevent inappropriate, inaccurate, or wasteful payments. This role will contribute to the full lifecycle of edit development—from opportunity identification to rules design, clinical validation, user acceptance testing, deployment, monitoring, and optimization.

The ideal candidate has strong claims domain expertise, analytic skills, and a deep understanding of coding, billing, medical policy, and payment integrity concepts.

This role must be performed from the CGI Office in Bogota, Colombia.

Key Responsibilities

• Edit Development & Implementation
• Identify high impact edit opportunities using claim data analysis
• Translate medical policy, CMS rules, coding guidance, and industry best practices into actionable edit logic
• Create rule specifications (conditions, exclusions, thresholds, flags)
• Design validation datasets and perform pre deployment testing
• Edit Monitoring & Optimization
• Track edit performance, yield, false positives, provider abrasion, and ROI
• Continuously refine edits based on results, coding updates, and provider behavior
• Maintain inventory of active edits with documentation and version control
• Identify obsolete or low value edits and retire/update accordingly
• Clinical & Coding Alignment
• Collaborate with Medical Directors for clinical validation
• Ensure edits comply with CMS coding policies, NCCI, LCD/NCD rules
• Work with internal auditors (RN/coding) to validate appropriateness
• Cross Functional Collaboration
• Partner with SIU, coding, claims operations, and policy.
• Communicate edit design and rationale to leadership
• Work with provider relations to address provider questions or disputes
• Provide reporting and dashboards for edit outcomes
• Governance & Documentation
• Maintain edit specifications, business rules, and performance logs
• Ensure each edit has testing artifacts
• Ensure compliance with regulatory and audit requirements (CMS/State)
  
  

Education: Bachelor's degree in business, healthcare, data analytics, public health, or related field or equivalent experience

Required Qualifications

• 5+ years of experience in payment integrity, claims analytics, medical policy, or coding
• Strong knowledge of CPT/HCPCS, ICD 10, DRG, APC/OPPS, NCCI bundling policies
• Coding certifications: CPC, CCS, COC, CPMA, RHIA, RHIT
• Experience in prepay editing or post pay audit logic
  
  

Preferred Qualifications

• SQL skills a plus
• Clinical licensure: RN
• Experience with claims rules platforms a plus (Optum/CES, Cotiviti, McKesson, internal rules engines)
• Creating Professional and Outpatient Edits/Concepts
  
  

Competencies

• Analytical & critical thinking
• Strong written communication
• Policy & regulatory fluency
• Project management & prioritization
• Ability to work cross functionally
• High attention to detail
  
  

Your future duties and responsibilities

Required Qualifications To Be Successful In This Role

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.

That same commitment to fairness extends to how we use technology. To support our recruitment team, AI tools may be used to help assess applications though they never replace human judgement. All hiring decisions remain entirely in the hands of our recruitment professionals.

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