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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 reviews, clinical judgment for claim payment decisions, and investigative skills to identify and address fraud in medical claims. Proficient in composing reports and correspondence while ensuring compliance with regulatory standards.
Highest-signal resume keywords
Medical Record ReviewClinical JudgmentInvestigative SkillsCPC CertificationNursing License
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claim Payment DecisionsMedical Claims ReviewFraud DetectionRegulatory ResearchData Analysis
Soft Skills
Strong Communication SkillsOrganizational SkillsAbility to Work IndependentlyTeam Collaboration
Tools & Technologies
PC KnowledgeFraud Investigation Tools
Certifications & Qualifications
CPC CertificationActive Nursing LicensePhysical Therapy License
Industry Keywords
Medicare PaymentsMedical NecessityRegulatory ViolationsFraud CasesConfidential Material
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
- Use tools to detect potential fraud and support fraud investigations and requests for information
- Identify and develop cases for future administrative action, including referral to law enforcement, 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 to uncover problems in Medicare payments to institutional and non-institutional providers
- Make claim payment decisions based on clinical knowledge
- Compose correspondence, reports, and referral summary letters
- Report work activity on a timely basis
- Attend meetings, training, and conferences
- Appear in court to testify about work findings when required
Requirements
What you’ll need- 5 years with BS/BA; 3 years with MS/MA; 0 years with PhD
- 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
- 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 (desirable)
- CPC (Certified Professional Coder) certificate (desirable)
- Ability to appear in court to testify about work findings
- Ability to compose correspondence, reports, and referral summary letters
- Ability to communicate effectively, internally and externally
- Ability to handle confidential material
- Ability to report work activity on a timely basis
- Ability to work independently and as a member of a team
- Ability to attend meetings, training, and conferences
- Overnight travel required
Benefits
Comp & perks- Medical insurance
- Dental insurance
- Vision insurance
- Life insurance
- Health savings account
- Short-term disability
- Long-term disability
- Employee assistance program (EAP)
- Parental leave
- 401(k)
- Paid time off (PTO) for vacation
- Company paid holidays
- Overtime eligibility
- Shift differential eligibility
- Discretionary bonus eligibility