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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, with a strong focus on Medicare and Medicaid guidelines. Proficient in assessing fraud, waste, and abuse while providing training and consultation to enhance benefit integrity investigations.
Highest-signal resume keywords
Medical Record ReviewClaims ReviewFraud AssessmentRN LicensureCoding 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 Review ExperienceData EntryField AuditsCase SummariesReporting
Soft Skills
ConsultationTraining DevelopmentCommunication
Certifications & Qualifications
RN LicensureCoding Certification
Industry Keywords
MedicareMedicaidBenefit IntegrityOverpaymentWasteAbuse
About the role
Key responsibilities & impact- Perform medical record and claims review for Medicare, Medicaid, and/or other claims data
- Ensure applicable guidelines have been followed
- Assess potential overpayment, fraud, waste, and abuse
- Review beneficiary, provider, and/or pharmacy cases
- Complete desk reviews and field audits
- 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
Requirements
What you’ll need- Minimum Bachelor's Degree required
- Current, active and non-restricted RN licensure required
- 2 - 4 years of experience required
- Medical Review experience
- Medicare experience preferred
- Coding certification preferred
- Willingness to complete pre-employment background and drug screens
Benefits
Comp & perks- Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities
- Drug-free workplace
- Pre-employment background and drug screens