Medical Chart Reviewer

Frontier AI Lab; United States; Remote; USD 55,000 - 96,000; Part time

Job summary

Remotebridge is seeking a Medical Chart Reviewer contractor to review and audit medical charts for accuracy of documentation and coding across diverse clinical settings. You will validate diagnoses, procedures, POA indicators, and MS-DRG assignments, applying ICD-10-CM/PCS guidelines and official coding guidance.

Collaboration with stakeholders will clarify requirements and improve data integrity. The role emphasizes identifying documentation gaps, providing actionable feedback, and maintaining

Qualifications

• Active coding credentials and chart review experience.
• Expertise in ICD-10-CM/PCS and MS-DRG coding.
• Experience in diverse clinical settings (acute care, transplant, oncology).
• Strong written and verbal communication skills.

Responsibilities

• Review and audit medical charts for accuracy and codes.
• Validate POA indicators and MS-DRG assignments.
• Apply ICD-10-CM/PCS guidelines and coding clinic guidance.
• Flag gaps and query opportunities.
• Collaborate with stakeholders to clarify requirements.
• Provide feedback to improve AI model understanding.

Skills

Attention to detail

Written and verbal communication

Analytical thinking

Education

AHIMA CCS

AAPC CIC

AAPC CPC

RN / clinical credential with chart review or CDI experience

Tools

ICD-10-CM/PCS

MS-DRG methodology

MS-DRG grouper tools

Official Coding Guidelines

Job description

Role Title: Medical Chart Reviewer

Role Type: Contractor

Location: US - Remote

Scope of Work

• 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.

Preferred Qualifications

• Active AHIMA Certified Coding Specialist (CCS), AAPC Certified Inpatient Coder (CIC), AAPC Certified Professional Coder (CPC), or an RN / clinical credential with chart review or CDI experience.
• Thorough expertise in ICD-10-CM, ICD-10-PCS, and MS-DRG methodology, with hands-on experience in chart review, coding audit, or clinical documentation improvement (CDI).
• 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.
• Strong written and verbal communication skills, demonstrating meticulous attention to detail and clarity.
• Access to current ICD-10-CM and ICD-10-PCS code sets, Official Coding Guidelines, and MS-DRG grouper tools.