Medical Chart Reviewer

What You'll Do8

• Examine and audit admission and progress notes, operative reports, consultations, lab and imaging results, and discharge summaries for complete and accurate documentation and coding.
• Check diagnosis and procedure codes, sequencing, Present on Admission indicators, and MS-DRG assignments against the clinical record.
• Identify under-coding, over-coding, and missed CCs or MCCs.
• Apply ICD-10-CM and ICD-10-PCS Official Guidelines, AHA Coding Clinic guidance, and clinical validation criteria.
• Flag documentation gaps and cases where a query may be appropriate.
• Communicate with project stakeholders in writing and verbally to clarify requirements, address documentation ambiguity, and protect data integrity.
• Provide feedback on charts, coding guidance, and complex cases to support project workflow improvements and AI model understanding.
• Check that review findings are accurate and complete in line with current coding standards and best practices.

Requirements4

• Bring medical chart review expertise through a CCS, CIC, or CPC certification, or an RN or other clinical background.
• Apply clinical documentation and coding knowledge to assess the accuracy of diagnoses, procedures, and MS-DRG assignments.
• Use written and verbal communication to clarify requirements and explain review findings.
• No prior AI experience is required.

Preferred Qualifications6

• Active AHIMA CCS, AAPC CIC, or AAPC CPC certification, or an RN or clinical credential with chart review or CDI experience.
• Strong command of ICD-10-CM, ICD-10-PCS, and MS-DRG methodology, with hands-on chart review, coding audit, or CDI experience.
• Chart review experience across settings such as acute care, teaching hospitals, specialty units, surgery, trauma, oncology, cardiology, or transplant.
• Experience reviewing varied clinical records and spotting discrepancies or complex coding issues.
• Careful attention to detail and clear written and verbal communication.
• Access to current ICD-10-CM and ICD-10-PCS code sets, Official Coding Guidelines, and MS-DRG grouper tools.

Who Should Apply

Medical coders and clinicians with chart review expertise will fit this project, especially those familiar with ICD-10-CM/PCS, MS-DRG methodology, and CDI or coding audits. The work suits candidates who can assess detailed records and communicate findings with clarity.

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