Medical Chart Reviewer

Gadsden Regional Medical Center; Gadsden (AL); On-site; USD 43,000 - 64,000; Full time

Job summary

Gadsden Regional Medical Center is seeking a Medical Chart Reviewer to ensure accuracy and completeness of patient records, support billing and coding accuracy, and uphold regulatory standards. The role involves reviewing charts, verifying documentation, and collaborating with clinical and clerical staff.

The successful candidate will analyze records for discrepancies, correct documentation issues, and participate in quality improvement initiatives while maintaining patient confidentiality and

Qualifications

• 1-3 years of experience in medical records review, health information management, or related field required.
• Strong understanding of medical records documentation and billing practices.
• Knowledge of healthcare regulatory standards, including HIPAA.
• Proficiency in using electronic health records (EHR) systems and associated software.
• Excellent communication and collaboration skills for working with healthcare professionals across multiple departments.
• Strong attention to detail and organizational skills.

Responsibilities

• Reviews and verifies the accuracy and completeness of patient medical records to ensure compliance with billing, coding, and documentation standards.
• Monitors daily reports to identify discrepancies in charges and ensures proper charge capture based on provider documentation.
• Collaborates with providers and staff to address documentation corrections, sending charts for review and updates as necessary.
• Maintains appropriate records and supply orders for special materials as required.
• Provides support and password resets for ancillary staff.
• Reviews observation charges and ensures appropriate documentation and charge capture.
• Maintains confidentiality of patient records and ensures compliance with regulatory standards.
• Assumes responsibility for the independent review of medical records, identifying problems and implementing solutions with minimal supervision.
• Consults with administration, health information management, and other relevant stakeholders regarding reimbursement, billing, and documentation protocols.
• Participates in quality improvement activities, assisting with data collection and reporting related to medical records.
• Assists with post-discharge chart analysis to identify deficiencies and trends, providing feedback to department leadership.
• Serves as a resource to administration and physicians, offering guidance on documentation best practices and regulatory requirements.
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.

Skills

Medical records review

HIPAA knowledge

Billing & coding

EHR proficiency

Communication

Attention to detail

Tools

EHR systems

Job description

Job Summary

The Medical Chart Reviewer is responsible for ensuring the accuracy and completeness of medical records. This role involves reviewing patient charts, verifying documentation, and ensuring appropriate charge capture for services provided. The Medical Chart Reviewer collaborates with clinical and clerical staff to identify discrepancies and works with relevant stakeholders to correct documentation issues. This role supports billing and coding accuracy and adherence to regulatory standards.

Essential Functions

• Reviews and verifies the accuracy and completeness of patient medical records to ensure compliance with billing, coding, and documentation standards.
• Monitors daily reports to identify discrepancies in charges and ensures proper charge capture based on provider documentation.
• Collaborates with providers and staff to address documentation corrections, sending charts for review and updates as necessary.
• Maintains appropriate records and supply orders for special materials as required.
• Provides support and password resets for ancillary staff.
• Reviews observation charges and ensures appropriate documentation and charge capture.
• Maintains confidentiality of patient records and ensures compliance with regulatory standards.
• Assumes responsibility for the independent review of medical records, identifying problems and implementing solutions with minimal supervision.
• Consults with administration, health information management, and other relevant stakeholders regarding reimbursement, billing, and documentation protocols.
• Participates in quality improvement activities, assisting with data collection and reporting related to medical records.
• Assists with post-discharge chart analysis to identify deficiencies and trends, providing feedback to department leadership.
• Serves as a resource to administration and physicians, offering guidance on documentation best practices and regulatory requirements.
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.

Qualifications

• 1-3 years of experience in medical records review, health information management, or related field required

Knowledge, Skills and Abilities

• Strong understanding of medical records documentation and billing practices.
• Knowledge of healthcare regulatory standards, including HIPAA.
• Ability to analyze medical records and identify discrepancies or areas for improvement.
• Proficiency in using electronic health records (EHR) systems and associated software.
• Excellent communication and collaboration skills for working with healthcare professionals across multiple departments.
• Strong attention to detail and organizational skills.
• Ability to work independently and manage time effectively in a fast-paced environment.