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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical coding and reimbursement processes, with a strong focus on compliance with CPT, CMS guidelines, and industry standards. Proficient in conducting clinical reviews and collaborating across departments to ensure accurate claims processing and recovery recommendations.
Highest-signal resume keywords
Certified Professional Coder (CPC)Certified Coding Specialist (CCS)Clinical Review ExperienceCPT Guidelines ComplianceCritical Thinking
About the role
Key responsibilities & impact- Review billed services, authorizations, plan benefit documents, itemized statements, medical records, discharge summaries, and detailed data reports
- Make reimbursement or recovery recommendations based on coding, billed statistics, policies, industry standards, and contractual, state, and federal regulations
- Support Health Plan departments with reviews and recommendations for correct coding, billing, and reimbursement
- Complete clinical reviews for Claims, Claim Edits, Appeals, and the Grievance process
- Assist with analysis of clinical risk for Underwriting, Pharmacy, and Finance departments
- Recommend recovery efforts based on contracts, policies, procedures, and industry standards
- Review and validate pended and reconsidered claims using CPT, industry, and CMS guidelines
- Review inpatient and outpatient high-dollar claims and assist with quality-concern reviews
- Validate claim payments based on Plan contracts, collaborating with Pharmacy and PNM departments
- Create and maintain reports tracking department data
- Participate in discussions on challenging medical reviews
- Assist with onboarding new team members
- Participate in selected workgroups and committees as requested
Requirements
What you’ll need- High School Diploma or Equivalent (GED) required
- Certified Professional Coder (CPC) through AAPC or Certified Coding Specialist (CCS) through AHIMA required
- Minimum of 3 years of relevant experience required
- Relevant experience may combine related work experience and/or completed specialty training program
- One year of specialty training counts as one year of relevant experience
- LPN preferred
- Minimum of 2 years of clinical experience preferred
- Computer literacy
- Critical thinking
- Organizing
- Secure work-from-home office compliant with HIPAA Privacy standards
- Ability to comply with organization policies and procedures
Benefits
Comp & perks- Healthcare benefits for full-time and part-time positions from day one
- Vision coverage
- Dental coverage
- Domestic partner benefits
- Work-from-home arrangement
- Occasional onsite department meetings as needed
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 CodingClaims ReviewReimbursement RecommendationsData AnalysisClinical Risk AssessmentQuality-Concerning ReviewsReport Creation and MaintenanceBilling Statistics AnalysisContractual ComplianceHIPAA Compliance
Soft Skills
Critical ThinkingOrganizingCollaborationCommunicationTeam Support
Tools & Technologies
Computer LiteracyData Reporting Tools
Certifications & Qualifications
Certified Professional Coder (CPC)Certified Coding Specialist (CCS)
Industry Keywords
Health PlanClaims ProcessingClinical ExperienceState RegulationsFederal RegulationsMedical Records ReviewDischarge SummariesPlan Benefit DocumentsPended ClaimsGrievance Process