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Posted: 10/20/2026Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical record and claims review, particularly for Medicare and Medicaid, while ensuring compliance with guidelines and identifying potential fraud and overpayment. Proficient in conducting audits, providing training, and participating in legal proceedings as necessary.
Highest-signal resume keywords
Medical Review ExperienceRN LicensureMedicare ExperienceFraud DetectionCoding Certification
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
- Testify at legal proceedings, as necessary
- Provide job-specific orientation and training
- Help develop training content, resources, and programs
- Plan and arrange own work and work with the manager to prioritize projects
Requirements
What you’ll need- Minimum Bachelor's Degree required
- 2 - 4 years of experience required; 5 - 7 years preferred
- Medical Review experience required
- Experience working with Medicare or Medicaid preferred
- Current, active and non-restricted RN licensure required
- Coding certification preferred
- Successful completion of pre-employment background and drug screens
- Must be able to participate in provider onsite visits and beneficiary interviews, as required, for field audits/investigations
- Must be able to testify at various legal proceedings, as necessary
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 ReviewData EntryField AuditsCase SummariesLegal TestimonyFraud AssessmentBeneficiary InterviewsProvider VisitsTraining DevelopmentProject Prioritization
Soft Skills
CommunicationCollaborationOrganizational SkillsAnalytical ThinkingProblem-Solving
Certifications & Qualifications
Coding CertificationRN Licensure
Industry Keywords
MedicareMedicaidBenefit IntegrityOverpaymentFraudWasteAbuseDesk ReviewsFocus GroupsLegal Proceedings