Clinical Nurse Auditor

Clinical Nurse Auditor

CGI is one of the world's largest independent IT and business consulting services firms. We partner with commercial and government clients to deliver innovative technology and business solutions that improve outcomes for millions of people. At CGI, you'll join a collaborative, client-focused organization where your expertise helps deliver meaningful impact while supporting continuous learning and professional growth. CGI is seeking a Clinical Nurse Auditor to join our Clinical Services Group (CSG) Clinical Audit Team. In this role, you will conduct comprehensive clinical audits of medical records to determine the medical appropriateness and necessity of healthcare services provided to members of commercial and government health plans. Your expertise will support the identification of improper payments while ensuring audit decisions are objective, well-supported, and aligned with applicable clinical guidelines, regulatory requirements, and client-specific policies.

As a Clinical Nurse Auditor, you will leverage your critical thinking, clinical expertise, and strong documentation skills to review inpatient and outpatient claims, evaluate medical necessity, validate clinical services, and prepare detailed audit determinations. You will receive comprehensive training on CGI's audit methodologies, documentation standards, and proprietary tools while participating in ongoing education related to clinical procedures, disease states, regulatory changes, and audit best practices. This position is remote within the United States, and candidates must be available to work Eastern Time Zone business hours.

Your future duties and responsibilities include conducting inpatient and outpatient clinical audits to evaluate medical necessity, reasonable and necessary services, prior authorization validation, clinical validation, medical service charge audits, and other audit types as required. You will review medical records and provider documentation to identify unsupported services and recover improper payments in accordance with client contracts and regulatory guidelines. Develop comprehensive audit rationales supported by clinical documentation, established review criteria, applicable regulations, and internal audit guidelines. Accurately document audit findings and determinations within CGI's audit platforms while maintaining thorough, well-organized case records. Collaborate with Physician Advisors and internal clinical specialists when required to support complex clinical determinations. Support Clinical Validation and DRG validation activities by documenting coding-related findings in partnership with specialized review teams. Maintain departmental productivity, quality, inter-rater reliability, and performance standards while meeting established deadlines. Communicate effectively with leadership regarding workload, scheduling, operational issues, and performance barriers while adhering to CGI corporate policies and compliance requirements.

Required qualifications to be successful in this role include an active, unrestricted Registered Nurse (RN) license in your state of residence, minimum of 5 years of recent Intensive Care Unit (ICU) or Critical Care Unit (CCU) nursing experience, strong clinical knowledge with the ability to evaluate complex medical records across multiple healthcare settings, experience interpreting clinical documentation to support medical necessity and utilization review determinations, excellent written communication skills with the ability to prepare detailed, well-supported clinical narratives using proper grammar and documentation standards, strong proficiency with Microsoft Office applications including Outlook, Word, and Excel, along with Windows-based operating systems, ability to work independently, manage multiple priorities, and consistently meet productivity and quality expectations, strong critical thinking, analytical, and decision-making skills with exceptional attention to detail, willingness to work Eastern Time Zone hours and travel up to 25% as needed for training or onsite audit activities.

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 $70,800.00 - $123,800.00. 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.