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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 and claims review for Medicare and Medicaid, ensuring compliance with guidelines while identifying potential overpayment and fraud. Proficient in conducting audits, providing training, and collaborating with stakeholders to enhance benefit integrity.
Highest-signal resume keywords
Medical Record ReviewClaims ReviewRN LicensureFraud DetectionCoding 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
Claims Data AnalysisDesk ReviewsField AuditsData EntryReporting
Soft Skills
CollaborationCommunicationTraining DevelopmentProject Prioritization
Certifications & Qualifications
RN LicensureCoding Certification
Industry Keywords
MedicareMedicaidBenefit IntegrityOverpaymentFraud Prevention
About the role
Key responsibilities & impact- Perform medical record and claims review for Medicare, Medicaid, and/or other claims data
- Ensure proper guidelines have been followed and assess potential overpayment, fraud, waste, and abuse
- Review beneficiary, provider, and/or pharmacy cases
- Complete desk reviews or field audits to meet contract requirements and identify evidence of potential overpayment or fraud
- Consult with benefit integrity investigation experts and pharmacists
- Complete case summaries and provide results to investigators
- Perform case-specific or plan-specific data entry and reporting
- Participate in internal and external focus groups as required
- Participate in provider onsite visits and beneficiary interviews for field audits/investigations as required
- Testify at legal proceedings as necessary
- Provide job-specific orientation and training
- Help develop training content, resources, and programs
- Plan and arrange own work with manager collaboration to prioritize projects
Requirements
What you’ll need- Minimum Bachelor's Degree required; can be substituted for experience
- 2–4 years of work experience required; 5–7 years preferred
- Current, active, and non-restricted RN licensure required
- Coding certification preferred
- Successful completion of pre-employment background and drug screens
Benefits
Comp & perks- Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities
- Drug-free workplace
- Employment offers contingent upon successful completion of pre-employment background and drug screens