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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in reviewing and auditing medical claims against patient records, ensuring compliance with CMS guidelines and payer policies. Possesses strong clinical knowledge and communication skills to collaborate effectively with multidisciplinary teams and support quality assurance initiatives.
Highest-signal resume keywords
Bachelor’s Degree In NursingActive State Nursing CertificationClinical/Hospital ExperienceAuditing ExperienceKnowledge Of US Healthcare System
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 ReviewClinical Documentation AuditingDiagnosis ValidationCoding Accuracy AssessmentCompliance MonitoringQuality Assurance ReviewsData AnalysisDocumentation Gap IdentificationProcess ImprovementTrend Monitoring
Soft Skills
Strong Written CommunicationStrong Oral CommunicationTeam CollaborationProblem-SolvingAttention To Detail
Certifications & Qualifications
Active State Nursing Certification
Industry Keywords
CMS GuidelinesPayer PoliciesRegulatory RequirementsCare-Management ConceptsMedical TerminologyAudit ReportsQuality BenchmarksProductivity StandardsSOPsTelecommuter Policy
About the role
Key responsibilities & impact- Review and audit medical claims against patient medical records to ensure accuracy and completeness of documentation
- Identify discrepancies between clinical documentation and billed services, highlighting variances and potential billing errors
- Perform detailed clinical reviews to validate diagnosis, procedures, and level of care in accordance with industry standards
- Ensure compliance with CMS guidelines, payer policies, and regulatory requirements during claim review processes
- Conduct best practice audits to identify documentation gaps, coding inaccuracies, and revenue leakage opportunities
- Provide structured findings and audit reports with clear recommendations for corrective action and process improvement
- Collaborate with coding, billing, and provider teams to resolve audit findings and support accurate claim submissions
- Monitor trends in audit results and identify recurring issues requiring targeted education or intervention
- Support quality assurance initiatives by maintaining audit accuracy benchmarks and meeting productivity standards
- Participate in continuous improvement activities, including updates on CMS regulations, clinical guidelines, and payer policy changes
- Perform audit based on clinical knowledge while reviewing the medical record
- Perform quality assurance reviews to assess comprehension of training efforts
- View all documented system information and additional records/data supporting a determination or recommendation
- Condense clinical information into a clear and precise clinical picture while making a final decision
- Analyze errors and approach the quality team for clarification when required
- Follow SOPs, project protocols, and process changes
- Complete audits with quality and achieve expected quality and production targets
- Update productivity, clarification, and other applicable logs daily
- Maintain alignment with the Manager/Team Lead on program delivery
- Respond promptly to emails
- Ensure compliance of the entire team
Requirements
What you’ll need- Bachelor’s degree in nursing
- Active State Nursing certification is mandatory
- Minimum 3 years of clinical/hospital experience is mandatory
- Strong written and oral communication skills
- Familiarity with basic medical terminology and care-management concepts
- Good understanding of the US healthcare system and management
- Ability to participate effectively in a multidisciplinary team
- Ability to work 40 hours per week as a full-time employee
- Shift: 08:00 AM to 05:00 PM IST, subject to project requirements
- High-speed broadband internet connection at home
- Must understand and adhere to the telecommuter policy
- Auditing experience is optional
Benefits
Comp & perks- 40 hours per week as Full-time employee
- Shift time: 08:00 AM TO 05:00 PM IST
- Weekends off
- High speed internet connection at home, must be broadband