Medical Chart Reviewer

• Review and audit medical charts, including admission notes, progress notes, operative reports, consults, lab and imaging results, and discharge summaries, to verify the accuracy and completeness of documentation and assigned codes.
• Validate diagnosis and procedure coding, sequencing, Present on Admission (POA) indicators, and MS-DRG assignment against the clinical documentation, identifying under-coding, over-coding, and missed CCs and MCCs.
• Apply clinical and coding standards, including the ICD-10-CM/PCS Official Guidelines for Coding and Reporting, AHA Coding Clinic guidance, and clinical validation criteria, while flagging documentation gaps and query opportunities.
• Collaborate with project stakeholders using both written and verbal communication to clarify requirements, resolve documentation ambiguities, and ensure data integrity.
• Deliver high-quality feedback on charts, coding guidelines, and complex cases to support project workflow improvements and enhance AI model understanding.
• Ensure accuracy and completeness of all review findings per current best practices and coding standards.

• domain knowledge is what matters.

• Access to current ICD-10-CM and ICD-10-PCS code sets, Official Coding Guidelines, and MS-DRG grouper tools.
• Experience reviewing charts in diverse settings, such as acute care, teaching hospitals, specialty units, surgical, trauma, oncology, cardiology, and transplant cases.
• Proficiency in reviewing various types of clinical documentation and identifying discrepancies or complex coding challenges.

RequiredAlso useful

Also listed: attention to detail, written and verbal communication, problem-solving.

Project and contracting process: the hiring partner. Applications continue on the provider's website.