Medical Chart Reviewer

Role Title: Medical Chart Reviewer

Role Type: Contractor

Location: US - Remote

The company is engaging Medical Chart Reviewers (CCS / CIC / CPC certified, or RN / clinical background) to contribute their expertise to a dynamic project for a valued customer. In this role, you’ll apply your expertise to help train next-generation AI systems. Your work will shape how models learn, reason, and perform through high-quality, real-world input. No prior experience in AI is required, your domain knowledge is what matters.

Scope of Work

1. 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.
2. 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.
3. 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.
4. Collaborate with project stakeholders using both written and verbal communication to clarify requirements, resolve documentation ambiguities, and ensure data integrity.
5. Deliver high-quality feedback on charts, coding guidelines, and complex cases to support project workflow improvements and enhance AI model understanding.
6. Ensure accuracy and completeness of all review findings per current best practices and coding standards.

Preferred Qualifications

1. 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.
2. 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).
3. Experience reviewing charts in diverse settings, such as acute care, teaching hospitals, specialty units, surgical, trauma, oncology, cardiology, and transplant cases.
4. Proficiency in reviewing various types of clinical documentation and identifying discrepancies or complex coding challenges.
5. Strong written and verbal communication skills, demonstrating meticulous attention to detail and clarity.
6. Access to current ICD-10-CM and ICD-10-PCS code sets, Official Coding Guidelines, and MS-DRG grouper tools.