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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical record review, fraud investigation, and compliance with Medicare regulations. Strong ability to communicate findings effectively and develop cases for administrative action.
Highest-signal resume keywords
Medical Record ReviewFraud InvestigationMedicare Regulations KnowledgeRegistered Nurse LicenseStrong Communication Skills
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 JudgmentData AnalysisTechnical Requirements ReviewFraud Case Development
Soft Skills
Investigative SkillsOrganizational SkillsEffective Communication
Tools & Technologies
Data Analysis ToolsPC Knowledge
Certifications & Qualifications
CPC (Certified Professional Coder)Nursing LicensePhysical Therapy License
Industry Keywords
Medicare PaymentsRegulatory ViolationsOverpayment RecoveryLaw-Enforcement ReferralConfidential Material Handling
About the role
Key responsibilities & impact- Conduct medical record reviews and apply sound clinical judgment to claim payment decisions
- Research medical claims data and other information to identify problems
- Review sophisticated data model output and use tools to detect potential fraud
- Support ongoing fraud investigations and requests for information
- Identify and develop cases for future administrative action, including law-enforcement referral, education, and overpayment recovery
- Work with external agencies to develop cases and corrective actions
- Respond to requests for data and support
- Present issues of concern, citing regulatory violations and alleging schemes or scams to defraud the Government
- Research regulations and cite violations
- Conduct self-directed research into Medicare payments to institutional and non-institutional providers
- Compose correspondence, reports, and referral summary letters
- Communicate effectively internally and externally
- Handle confidential material
- Report work activity on a timely basis
- Attend meetings, trainings, and conferences as needed
- Potentially appear in court to testify about work findings
Requirements
What you’ll need- Bachelor's degree and 5 years of experience, Master's degree and 3 years of experience, or Associate's degree and 7 years of experience
- At least 3 years of experience in the medical field as a Registered Nurse or other clinician, and/or experience in review of medical claims for coverage and medical necessity
- Current/Active Nursing or Physical Therapy license in state of residence
- Strong investigative skills
- Strong communication and organization skills
- Strong PC knowledge and skills
- U.S. citizenship required
- Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
- Knowledge of Medicare requirements, laws, rules and regulations related to payment for services billed
- CPC (Certified Professional Coder) certificate desirable
Benefits
Comp & perks- Telework available from contiguous United States
- Overnight travel may be required
- Employees may be eligible for overtime, shift differential, and a discretionary bonus in addition to base pay
- Equal opportunity employer, including disability and protected veterans, or other characteristics protected by law