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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 for accuracy and compliance with CMS guidelines and payer policies. Proficient in preparing audit reports and collaborating with multidisciplinary teams to enhance documentation and billing processes.
Highest-signal resume keywords
Bachelor's Degree In NursingActive State Nursing CertificationClinical/Hospital ExperienceStrong Written And Oral Communication SkillsUnderstanding Of The 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 ReviewAudit ReportingCompliance ValidationDocumentation AuditingQuality Assurance Reviews
Soft Skills
Effective Team ParticipationStrong Communication Skills
Certifications & Qualifications
Active State Nursing Certification
Industry Keywords
CMS GuidelinesPayer PoliciesClinical DocumentationMedical TerminologyRevenue Leakage
About the role
Key responsibilities & impact- Review and audit medical claims against patient medical records for accuracy and completeness
- Identify discrepancies between clinical documentation and billed services, including potential billing errors
- Validate diagnoses, procedures, and levels of care against industry standards
- Ensure compliance with CMS guidelines, payer policies, and regulatory requirements
- Conduct best-practice audits to identify documentation gaps, coding inaccuracies, and revenue leakage opportunities
- Prepare structured audit reports with corrective-action and process-improvement recommendations
- Collaborate with coding, billing, and provider teams to resolve audit findings and support accurate claim submissions
- Monitor audit-result trends and recurring issues requiring education or intervention
- Perform quality assurance reviews and maintain audit accuracy and productivity standards
- Update knowledge of CMS regulations, clinical guidelines, and payer policy changes
- Maintain productivity, clarification, and other required logs
- Coordinate with managers and team leads on program delivery
- Respond promptly to emails and follow SOPs, project protocols, and process changes
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 concepts used in care management
- Good understanding of the US healthcare system and management
- Ability to participate effectively in a multidisciplinary team
- Shift availability: 08:00 AM to 05:00 PM IST, subject to project requirements
- Must understand and adhere to the telecommuter policy
- Auditing experience is optional
Benefits
Comp & perks- Full-time schedule of 40 hours per week
- Weekends off
- High-speed broadband internet connection at home
- Hybrid work arrangement
- Opportunity to participate in continuous improvement activities and process training