Proven experience in prepay editing or post-pay audit logic. Education: Bachelor's degree in ... Proficiency in SQL and experience with claims rules platforms (e.g., Optum/CES, Cotiviti, McKesson)
Proven experience in prepay editing or post-pay audit logic. Education: Bachelor's degree in ... Proficiency in SQL and experience with claims rules platforms (e.g., Optum/CES, Cotiviti, McKesson)
Optum Claims Editing information
What is Optum Claims Editing?
Optum Claims Editing refers to the process and technology used by Optum, a health services company, to review and validate healthcare claims before they are submitted for payment. This process helps ensure claims are accurate, comply with payer rules and regulations, and identify potential errors or fraud. The claims editing system applies automated rules to check information such as coding accuracy, eligibility, and medical necessity. By catching issues early, Optum helps healthcare providers reduce claim denials and speed up reimbursement. Many organizations use Optum's solutions to streamline their revenue cycle and improve overall claims management.
What are the key skills and qualifications needed to thrive as an Optum Claims Editing specialist?
To thrive as an Optum Claims Editing Specialist, you need a solid understanding of medical billing, coding (such as ICD-10, CPT, and HCPCS), and health insurance processes, often supported by a degree in healthcare administration or a coding certification. Familiarity with claims editing systems like Optum CES, payer portals, and healthcare management software is essential. Attention to detail, analytical thinking, and strong communication skills help ensure accurate claim review and collaboration with providers. These skills are critical for minimizing claim denials, ensuring compliance, and optimizing healthcare reimbursements.
What are some common challenges faced in an Optum Claims Editing role, and how can I effectively address them?
In an Optum Claims Editing role, you may frequently encounter complex claim discrepancies, policy updates, and high volumes of claims requiring timely review. Staying current with insurance regulations and payer guidelines is key to minimizing errors and rework. Collaborating closely with team members, leveraging internal resources, and participating in ongoing training can help you stay effective and maintain accuracy. Proactively communicating with supervisors and cross-functional teams also ensures smoother resolution of challenging claims.
What is the difference between Optum Claims Editing vs Medical Billing Specialist?
| Aspect | Optum Claims Editing | Medical Billing Specialist |
|---|---|---|
| Credentials | Certification in claims processing or related fields often preferred | Certification in medical billing or coding often preferred |
| Work Environment | Healthcare insurance companies, third-party administrators | Medical offices, hospitals, billing companies |
| Employer & Industry | Insurance providers, healthcare payers | Healthcare providers, billing services |
| Primary Focus | Reviewing and editing insurance claims for accuracy | Preparing and submitting medical bills to insurers |
Optum Claims Editing specialists focus on reviewing and correcting insurance claims to ensure proper reimbursement, often working within insurance companies or third-party administrators. Medical Billing Specialists handle the entire billing process, including preparing and submitting claims to insurers. While both roles require knowledge of healthcare billing and insurance processes, Optum Claims Editing emphasizes claim accuracy and compliance, whereas Medical Billing Specialists focus on the end-to-end billing cycle.
What are popular job titles related to Optum Claims Editing jobs in Tennessee?
For Optum Claims Editing jobs in Tennessee, the most frequently searched job titles are:
What job categories do people searching Optum Claims Editing jobs in Tennessee look for?
The top searched job categories for Optum Claims Editing jobs in Tennessee are:
What cities in Tennessee are hiring for Optum Claims Editing jobs?
Cities in Tennessee with the most Optum Claims Editing job openings:
Full-time
Retirement, PTO
Re-posted 7 days ago
CGI rating
7.1
Based on 19 frontline employees who took The Breakroom Quiz
149th of 226 rated it services
Job description
Senior Analyst, Edits | Payment Integrity (Remote)
Category: Analytics and Emerging Digital Technologies
Main location: United States, Tennessee, Knoxville
Alternate Location(s): United States, Georgia, Atlanta
United States, North Carolina, Charlotte
United States, Virginia, Fairfax
United States, Texas, Dallas
United States, Texas, Houston
Position ID:J0126-0518
Employment Type: Full Time
Position Description:
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.
Your future duties and responsibilities:
1. 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).
2. 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.
3. 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.
4. 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.
Required qualifications to be successful in this role:
Certifications (Must-Have): Active coding certification (CCS or CPC) with deep clinical coding expertise.
Professional Experience: 5+ years in payment integrity, claims analytics, medical policy, or coding.
Technical Knowledge: Deep expertise in CPT/HCPCS, ICD-10, DRG, APC/OPPS, and NCCI bundling policies.
Domain Expertise: Proven experience in prepay editing or post-pay audit logic.
Education: Bachelor's degree in Business, Healthcare, Data Analytics, Public Health, or a related field (or equivalent experience).
Preferred Skills
Technical Tools: Proficiency in SQL and experience with claims rules platforms (e.g., Optum/CES, Cotiviti, McKesson).
Clinical Background: Current RN licensure.
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 $75,000.00 - $100,000.00.
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:
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.
Category: Analytics and Emerging Digital Technologies
Main location: United States, Tennessee, Knoxville
Alternate Location(s): United States, Georgia, Atlanta
United States, North Carolina, Charlotte
United States, Virginia, Fairfax
United States, Texas, Dallas
United States, Texas, Houston
Position ID:J0126-0518
Employment Type: Full Time
Position Description:
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.
Your future duties and responsibilities:
1. 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).
2. 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.
3. 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.
4. 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.
Required qualifications to be successful in this role:
Certifications (Must-Have): Active coding certification (CCS or CPC) with deep clinical coding expertise.
Professional Experience: 5+ years in payment integrity, claims analytics, medical policy, or coding.
Technical Knowledge: Deep expertise in CPT/HCPCS, ICD-10, DRG, APC/OPPS, and NCCI bundling policies.
Domain Expertise: Proven experience in prepay editing or post-pay audit logic.
Education: Bachelor's degree in Business, Healthcare, Data Analytics, Public Health, or a related field (or equivalent experience).
Preferred Skills
Technical Tools: Proficiency in SQL and experience with claims rules platforms (e.g., Optum/CES, Cotiviti, McKesson).
Clinical Background: Current RN licensure.
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 $75,000.00 - $100,000.00.
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.