j0121-2011 - clinical nurse Auditor (for future opening)CGI

The Clinical Nurse Auditor is responsible for reviewing medical records to determine the medical appropriateness in a variety of care settings for clinical services rendered to beneficiaries of various health plans, including Commercial and Government Clients.
Your future duties and responsibilities:
Conducts inpatient and outpatient claim audits to determine medical necessity/reasonable and necessary services, validation of prior authorization, clinical validation, medical service charge audit, or other audit types as required, thereby recovering improper payments when it is determined through the audit process that the medical record does not support the services billed. Other types of audits may be performed as required by the Client.
 Develops rationale for the audit decision based on the provider's submitted information, citing appropriate review guidelines, applicable regulations and/or internal review guidelines, and enters clearly documented information in CAS / ProperPay. Follows the designated procedure for referral to a Physician Advisor if required by Client contract.
 For Clinical Validation audits, documents specified coding issues in conjunction with the DRG Validation Team as assigned.
 Follows CGI Federal policies and processes, completing mandatory training, timesheets, payroll, travel expense documents, and other corporate requirements in a timely manner.
 Communicates timely with Team Lead required regarding illness, appointments, vacation requests, changes in work schedule, performance barriers, and computer issues.
 Complies with department standards regarding productivity and audit quality.
 Performs other duties as assigned.
Required qualifications to be successful in this role:
 Registered Nurse with active, unrestricted licensure through the Board or Agency
 Critical care experience (i.e. ICU, trauma, emergency) of 5 years or more is required
 Proficient in computer functions, Microsoft Office (Outlook, Word, Excel) applications, and Windows operating systems is a must
 Utilizes skills to write a well-reasoned review in narrative style, with accurate spelling, grammar, punctuation, and sentence structure
 Must be able to work independently, adapt to changing priorities, and meet department productivity standards and deadlines
 Amenable to working in shifting schedule
 Willing to work in Pasig
What you can expect from us:
Build your career with us.
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.
CGI

Manila City, Metro Manila Pasig City, Metro Manila
Permanent
Part-time