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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in conducting clinical quality audits and medical record reviews, ensuring compliance with accreditation standards and quality measures. Proficient in data analysis, documentation verification, and providing actionable insights to enhance clinical practices.
Highest-signal resume keywords
Clinical Quality AuditingRN LicenseHEDIS KnowledgeCPT Coding KnowledgeData Analysis
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Quality Chart ReviewsData AbstractionDocumentation VerificationQuality ImprovementRegulatory ComplianceAudit Findings PreparationCorrective Action PlanningCoded Data ReviewDocumentation Gap IdentificationAccreditation Standards Knowledge
Soft Skills
Attention to DetailOrganizational SkillsTime ManagementAnalytical Problem-SolvingCommunication Skills
Tools & Technologies
Electronic Health RecordsMicrosoft OfficeAdobe AcrobatWindowsTeamsSharePointOneNoteOneDrive
Certifications & Qualifications
RN LicenseCCACPCCPC-PCPC-HCCSCCS-PRHITRHIA
Industry Keywords
CMS CostNCQARADVQuality MeasuresAccreditation
About the role
Key responsibilities & impact- Conduct medical record reviews and clinical quality audits across Medica’s network
- Collect, review, and validate clinical documentation for compliance with quality standards
- Identify documentation gaps and improvement opportunities using established criteria
- Prepare audit findings supporting quality reporting and corrective action planning
- Maintain accurate documentation of review activities
- Perform data abstraction and documentation verification for required quality measures
- Ensure accuracy and completeness of data submitted for accreditation and ratings programs
- Collaborate with internal partners to clarify clinical requirements and documentation needs
- Monitor trends and raise concerns affecting regulatory or accreditation outcomes
- Complete audits related to CMS Cost, HEDIS, RADV, NCQA site visits, and other regulatory requirements
- Review coded data and medical records for accuracy and compliance
- Identify discrepancies and recommend corrective actions
- Contribute data and insights to audit readiness and regulatory submissions
- Provide feedback and guidance to providers on documentation expectations and audit results
- Share clinical and coding insights with providers and internal teams
- Support corrective action plans through education and follow-up
- Recommend enhancements to review methods, tools, or workflows
- Support process updates improving accuracy, consistency, or efficiency
- Collaborate with colleagues to align practices with evolving regulatory and accreditation standards
- Perform other duties as assigned
Requirements
What you’ll need- Associate’s or Bachelor's degree in Nursing
- 5+ years of related work experience, including clinical quality chart reviews, data analysis, auditing and/or quality improvement experience
- RN License required
- Current coding certification: CCA, CPC, CPC-P, CPC-H, CCS, CCS-P, RHIT, or RHIA; or ability to obtain CPC or CRC coding certification within 1 year of employment or by Medica-determined timeframe
- Experience and/or knowledge of HEDIS, NCQA, RADV, or other accreditation and quality measures strongly preferred
- Knowledge of CPT and diagnosis codes strongly preferred
- Ability to manage competing priorities and multiple deadlines
- Demonstrated organizational and time management skills
- Ability to make reliable independent decisions using analytical problem-solving skills
- Strong attention to detail
- Excellent written and verbal communication skills
- Experience navigating electronic health records preferred
- Proficiency with personal computers and software including Adobe Acrobat, Windows, Microsoft Office, Word, Excel, Outlook, Teams, SharePoint, OneNote, and OneDrive
- Primary home address must be in a state where Medica is registered as an employer: Arkansas, Arizona, Florida, Georgia, Iowa, Illinois, Kansas, Kentucky, Michigan, Minnesota, Missouri, North Dakota, Nebraska, Oklahoma, South Dakota, Tennessee, Texas, Virginia, or Wisconsin
- Must be legally authorized to work in the United States at the time of application
- Medica does not offer work visa sponsorship for this role
Benefits
Comp & perks- Competitive medical, dental, and vision benefits
- PTO
- Holidays
- Paid volunteer time off
- 401K contributions
- Caregiver services
- Other total rewards benefits