Senior Analyst, Edits

CGI•Knoxville, TN

5d•$75,000 - $100,000

About The Position

CGI is seeking a results-oriented Senior Analyst to join our growing Edits team. In this pivotal role, you will be responsible for expansively growing CGI’s edits library and driving measurable value by identifying and preventing improper payments. As a Senior Analyst, you will manage the full lifecycle of edit development—from initial opportunity identification to rules design, clinical validation, and deployment. You will serve as a subject matter expert, blending deep coding domain expertise with advanced analytics to ensure payment accuracy and integrity across the healthcare landscape.

Requirements

Active coding certification (CCS or CPC) with deep clinical coding expertise.
5+ years in payment integrity, claims analytics, medical policy, or coding.
Deep expertise in CPT/HCPCS, ICD-10, DRG, APC/OPPS, and NCCI bundling policies.
Proven experience in prepay editing or post-pay audit logic.
Bachelor’s degree in Business, Healthcare, Data Analytics, Public Health, or a related field (or equivalent experience).

Nice To Haves

Proficiency in SQL and experience with claims rules platforms (e.g., Optum/CES, Cotiviti, McKesson).
Current RN licensure.

Responsibilities

Edit Development & Implementation Identify Opportunities: Use claim data analysis to pinpoint high-impact edit opportunities.
Translate Policy: Convert medical policy, CMS rules, and coding guidance into actionable logic.
Technical Design: Create detailed rule specifications, including conditions, exclusions, thresholds, and flags.
Validation: Design validation datasets and lead rigorous pre-deployment user acceptance testing (UAT).
Monitoring & Optimization Performance Tracking: Monitor yield, false positives, ROI, and provider abrasion.
Continuous Improvement: Refine edits based on real-world results, coding updates, and provider behavior.
Lifecycle Management: Maintain a documented inventory of active edits and retire obsolete or low-value rules.
Clinical & Coding Alignment Validation: Partner with Medical Directors and internal auditors (RNs/Coders) to ensure clinical appropriateness.
Compliance: Ensure all edits strictly comply with CMS coding policies, NCCI, and LCD/NCD rules.
Cross-Functional Collaboration Stakeholder Engagement: Partner with SIU, claims operations, and policy teams to align on strategy.
Communication: Present edit design rationale and performance dashboards to leadership.