1. Medical Record Review:

• Thoroughly review medical records, including patient charts, physician notes, and diagnostic reports, to ensure all required documentation is present and accurate.
• Assess the completeness of medical records in relation to patient care provided, ensuring all diagnoses, procedures, and treatments are documented in line with healthcare standards.
• Ensure that the medical records comply with legal, regulatory, and payer-specific documentation requirements.

2. Coding Compliance and Accuracy:

• Verify that medical records are properly coded according to the appropriate classification systems (ICD-10, CPT, HCPCS).
• Identify and address discrepancies or errors in coding or documentation to ensure compliance with coding guidelines and payer regulations.
• Collaborate with medical coders, physicians, and other healthcare professionals to resolve documentation or coding issues.

3. Audit and Quality Assurance:

• Participate in audits of medical records to ensure coding accuracy, compliance with billing standards, and adherence to quality benchmarks.
• Identify potential issues or areas for improvement in medical record documentation and suggest corrective actions to improve the overall quality and accuracy of records.
• Conduct internal audits to assess the quality and completeness of medical records and provide feedback on compliance with internal policies and regulatory standards.

4. Training and Guidance:

• Provide guidance and support to physicians, coders, and other healthcare professionals to improve the accuracy and completeness of medical documentation.
• Assist in training staff on documentation best practices, regulatory requirements, and coding standards.
• Support continuous education and awareness programs to ensure team members are up-to-date with the latest coding standards, healthcare regulations, and payer requirements.

5. Documentation and Reporting:

• Accurately document any findings, discrepancies, or corrective actions taken during the review of medical records.
• Prepare and submit detailed reports on audit findings, performance trends, and opportunities for process improvements.
• Maintain confidentiality and adhere to privacy standards in handling sensitive patient data.

6. Collaboration and Communication:

• Communicate effectively with healthcare providers, coders, and quality assurance teams to clarify ambiguities in medical documentation.
• Collaborate with other departments (e.g., Medical Coding, Billing, Operations) to ensure that medical record review processes align with organizational goals and compliance requirements.
• Address any coding or documentation issues that may arise and work collaboratively with other teams to resolve them efficiently.

7. Process Improvement:

• Continuously evaluate and improve the medical record review process to enhance accuracy, efficiency, and compliance with healthcare standards.
• Identify trends and recurring issues in medical documentation, coding, or billing and propose solutions for improvement.
• Implement best practices to streamline medical record documentation and improve workflow efficiency.Data Entry