FREE ACCESS
5,000–10,000 jobs/day
See all jobs on JobTailor
Search thousands of fresh jobs every day.
Discover
- Fresh listings
- Fast filters
- No subscription required
Create a free account and start exploring right away.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in auditing medical claims and ensuring compliance with CMS guidelines and payer policies. Proficient in clinical documentation review, quality assurance, and effective communication within multi-disciplinary teams.
Highest-signal resume keywords
Bachelor’s Degree In NursingActive State Nursing CertificationClinical Auditing ExperienceQuality Assurance ReviewsKnowledge 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 AnalysisAudit ReportingError IdentificationCompliance Monitoring
Soft Skills
Strong Written CommunicationOral Communication SkillsTeam CollaborationProblem-SolvingAttention To Detail
Certifications & Qualifications
Active State Nursing Certification
Industry Keywords
CMS GuidelinesPayer PoliciesClinical GuidelinesHealthcare ComplianceMedical Terminology
About the role
Key responsibilities & impact- Review and audit medical claims against patient medical records for accuracy and completeness
- Identify discrepancies between clinical documentation and billed services, including potential billing errors
- Conduct clinical reviews to validate diagnoses, procedures, and level of care according to industry standards
- Ensure compliance with CMS guidelines, payer policies, and regulatory requirements
- Conduct best-practice audits to identify documentation gaps, coding inaccuracies, and revenue leakage opportunities
- Prepare structured audit reports with findings and corrective-action recommendations
- Collaborate with coding, billing, and provider teams to resolve audit findings and support accurate claim submissions
- Monitor audit trends and recurring issues requiring education or intervention
- Support quality assurance initiatives and maintain audit accuracy and productivity standards
- Participate in continuous improvement activities involving CMS regulations, clinical guidelines, and payer policy changes
- Review all documented system information and additional supporting records/data before making determinations or recommendations
- Condense clinical information into a clear and precise clinical picture and make final decisions
- Maintain process knowledge, follow changes, SOPs, and project protocols
- Complete audits with quality and meet production targets
- Maintain daily productivity and clarification logs
- Align with the Manager/Team Lead on program delivery
- Respond promptly to emails
- Ensure compliance across the 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 (documentation) and oral communication skills
- Familiarity with basic medical terminology and concepts used in care management
- Ability to effectively participate in a multi-disciplinary team including internal and external participants
- Good understanding of US healthcare system and management
- Ability to perform audits based on clinical knowledge while reviewing medical records
- Ability to perform quality assurance reviews
- Ability to analyze errors and approach the quality team for clarification when required
- Ability to follow SOPs, project-related protocols, and instructions
- Ability to achieve expected quality and production targets
- Ability to update productivity, clarification, and other applicable logs daily
- Shift time: 08:00 AM to 05:00 PM IST, subject to change based on project requirements
Benefits
Comp & perks- 40 hours per week as Full-time employee
- Weekends off
- High Speed internet connection at home, must be broadband
- Must understand and adhere with telecommuter policy