Medical Chart Reviewer

Clinical chart review for AI

Contribute coding or clinical review expertise to a project that trains AI systems. This contractor role is remote within the United States and does not require previous AI experience.

Review responsibilities

• Audit admission and progress notes, operative reports, consultations, laboratory and imaging results, and discharge summaries for complete, accurate documentation and coding.
• Validate diagnoses, procedures, code sequencing, Present on Admission indicators and MS-DRG assignments against the clinical record.
• Identify coding that understates or overstates the record, as well as missed complications or comorbidities and major complications or comorbidities.
• Follow official ICD-10-CM/PCS coding and reporting guidance, AHA Coding Clinic advice and clinical validation criteria.
• Flag documentation gaps and opportunities for clarification, then collaborate with stakeholders to resolve ambiguity and maintain data integrity.
• Provide accurate, complete review findings and useful feedback on charts, coding guidance and complex cases.

Preferred credentials and experience

Preferred backgrounds include active CCS, CIC or CPC certification, or an RN or other clinical credential with chart review or clinical documentation improvement experience. Detailed knowledge of ICD-10-CM, ICD-10-PCS and MS-DRG methods should be supported by practical chart review, coding audit or documentation improvement work.

Experience may include acute care, teaching hospitals, specialist units, surgery, trauma, oncology, cardiology and transplant cases. Confidence reviewing varied clinical documents and identifying complex discrepancies is useful.

References and collaboration

Access to current ICD-10-CM and ICD-10-PCS code sets, official guidance and MS-DRG grouper tools is preferred. Strong written and spoken communication, clear explanations and close attention to detail support the review process.