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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in reviewing and auditing medical claims, ensuring compliance with CMS guidelines and payer policies. Proficient in clinical documentation analysis, quality assurance, and effective communication within multidisciplinary teams.
Highest-signal resume keywords
Bachelor’s Degree In NursingActive State Nursing CertificationClinical Review And Audit ExperienceStrong Written And Oral Communication SkillsUnderstanding Of US Healthcare System
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Claims ReviewClinical Documentation AnalysisAudit ReportingCoding Accuracy AssessmentQuality Assurance Reviews
Soft Skills
Effective Team CollaborationProfessional CommunicationProblem-Solving
Certifications & Qualifications
Active State Nursing Certification
Industry Keywords
CMS GuidelinesPayer PoliciesRegulatory ComplianceMedical TerminologyCare Management Concepts
About the role
Key responsibilities & impact- Review and audit medical claims against patient medical records for accurate and complete documentation
- Identify discrepancies between clinical documentation and billed services, including potential billing errors
- Conduct clinical reviews to validate diagnoses, procedures, and level of care against industry standards
- Ensure compliance with CMS guidelines, payer policies, and regulatory requirements
- Perform best-practice audits to identify documentation gaps, coding inaccuracies, and revenue leakage opportunities
- Prepare structured audit reports with recommendations for corrective action and process improvement
- Collaborate with coding, billing, and provider teams to resolve audit findings and support accurate claim submissions
- Monitor audit trends and recurring issues requiring education or intervention
- Support quality assurance initiatives and meet audit accuracy and productivity standards
- Review medical records using clinical knowledge and make clear, precise determinations
- Perform quality assurance reviews and complete audits accurately
- Maintain productivity, clarification, and other applicable logs
- Follow SOPs, project protocols, process updates, and manager/team-lead alignment
- Respond promptly to emails and maintain a professional work environment
Requirements
What you’ll need- Bachelor’s degree in nursing
- Active State Nursing certification is Mandatory
- Minimum 3 years of clinical/hospital experience is mandatory
- Strong written (documentation) and oral communication skills
- Familiarity with basic medical terminology and care management concepts
- Good understanding of the US healthcare system and management
- Ability to participate effectively in a multidisciplinary team
- Must understand and adhere to the telecommuter policy
- Must work 40 hours per week as a full-time employee
- Shift: 08:00 AM to 05:00 PM IST, subject to project requirements
Benefits
Comp & perks- Full-time schedule of 40 hours per week
- Weekends off
- Hybrid work arrangement
- High-speed broadband internet connection at home
- Telecommuter policy support