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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 healthcare claims. Proficient in communication and organization, with a strong understanding of regulatory compliance and medical necessity.
Highest-signal resume keywords
Medical Record ReviewClinical JudgmentFraud InvestigationRegistered Nurse LicenseCPC Certification
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 ReviewFraud DetectionData AnalysisRegulatory ResearchClaim Payment Decision Making
Soft Skills
Strong Communication SkillsOrganizational SkillsInvestigative Skills
Tools & Technologies
PC Knowledge
Certifications & Qualifications
CPC CertificationCurrent Nursing License
Industry Keywords
Medicare PaymentsRegulatory ViolationsOverpayment RecoveryFraud CasesHealthcare Compliance
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
- Utilize tools to detect potential fraud and support ongoing 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 and 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 made to institutional and non-institutional providers
- Make claim payment decisions based on clinical knowledge
- Compose correspondence, reports, and referral summary letters
- Communicate effectively internally and externally
- Handle confidential material
- Report work activity on a timely basis
- Attend meetings, training, and conferences; overnight travel required
- Appear in court to testify about work findings when required
Requirements
What you’ll need- 2 years with BS/BA or 4 years with an Associates degree, or 6 years with a HS diploma/equivalent
- 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 nursing license
- Strong investigative skills
- Strong communication and organization skills
- Strong PC knowledge and skills
- US. citizenship required
- Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases (most competitive candidates)
- CPC (Certified Professional Coder) certificate (most competitive candidates)
Benefits
Comp & perks- medical insurance
- dental insurance
- vision insurance
- life insurance
- health savings account
- short/long term disability
- EAP
- parental leave
- 401(k)
- paid time off (PTO) for vacation
- company paid holidays
- overtime eligibility
- shift differential eligibility
- discretionary bonus eligibility