Medical Documentation Reviewer Job Description [Updated for 2025]

In the era of advanced healthcare technology, the focus on medical documentation reviewers has never been more critical.

As healthcare progresses, the demand for professionals who can analyze, verify, and maintain the integrity of our medical records grows stronger.

But let’s delve deeper: What’s truly expected from a medical documentation reviewer?

Whether you are:

• A job seeker trying to understand the crux of this role,
• A hiring manager outlining the perfect candidate,
• Or simply fascinated by the intricacies of medical documentation review,

You’ve come to the right place.

Today, we present a customizable medical documentation reviewer job description template, designed for easy posting on job boards or career sites.

Let’s dive right in.

Medical Documentation Reviewer Duties and Responsibilities

Medical Documentation Reviewers play a crucial role in the healthcare industry by ensuring that all patient records are accurate, complete, and comply with regulations and standards.

They are also responsible for identifying discrepancies in medical documentation and rectifying them.

Their daily duties and responsibilities include:

• Reviewing medical records for completeness, accuracy, and compliance with regulations
• Identifying any discrepancies or inconsistencies in medical documentation
• Communicating effectively with healthcare professionals to clarify diagnoses or to obtain additional information
• Ensuring all health records are kept in compliance with applicable ethical, legal, and regulatory requirements
• Examining records to ensure they are assembled in standard order and that all necessary forms are included
• Using classification systems software to assign clinical codes for insurance reimbursement and data analysis
• Protecting the security of medical records to ensure that confidentiality is maintained
• Training staff members on record-keeping processes and policies, and ensuring they are implemented correctly

 

Medical Documentation Reviewer Job Description Template

Job Brief

We are seeking a detail-oriented Medical Documentation Reviewer to join our team.

The ideal candidate will be responsible for reviewing and analyzing medical records, verifying their accuracy, and ensuring that they comply with legal and ethical standards.

The Medical Documentation Reviewer will perform audits on patient files, cross-check information with the appropriate medical coding system, and liaise with healthcare professionals to clarify diagnoses or to obtain additional information.

The successful candidate should be familiar with medical terminology and coding, have excellent attention to detail, and possess strong analytical skills.

 

Responsibilities

• Review and analyze medical documentation for accuracy and completeness
• Verify that documentation complies with legal and ethical standards
• Perform audits on patient files to identify discrepancies or inconsistencies
• Utilize medical coding systems to cross-check information in patient files
• Liaise with healthcare professionals to clarify diagnoses or to obtain additional information
• Prepare reports on audit findings and make recommendations for improvements
• Stay updated on changes in medical terminology, coding practices, and regulatory guidelines

 

Qualifications

• Proven work experience as a Medical Documentation Reviewer or similar role in the healthcare industry
• Knowledge of medical terminology and coding practices
• Excellent attention to detail and strong analytical skills
• Ability to communicate effectively with medical professionals
• Proficiency in electronic health records software
• Registered Health Information Technician (RHIT) or Certified Professional Coder (CPC) certification is a plus
• Associate or bachelor’s degree in Health Information Management or related field

 

Benefits

• 401(k)
• Health insurance
• Dental insurance
• Retirement plan
• Paid time off
• Professional development opportunities

 

Additional Information

• Job Title: Medical Documentation Reviewer
• Work Environment: Office setting within a healthcare facility. May require occasional travel to other healthcare facilities.
• Reporting Structure: Reports to the Health Information Manager or Medical Records Supervisor.
• Salary: Salary is based upon candidate experience and qualifications, as well as market and business considerations.
• Pay Range: $45,500 minimum to $74,200 maximum
• Location: [City, State] (specify the location or indicate if remote)
• Employment Type: Full-time
• Equal Opportunity Statement: We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
• Application Instructions: Please submit your resume and a cover letter outlining your qualifications and experience to [email address or application portal].

 

What Does a Medical Documentation Reviewer Do?

Medical Documentation Reviewers typically work in healthcare facilities, such as hospitals, clinics, and nursing homes, or for health insurance companies.

They can also be employed by companies that provide medical coding and billing services.

Their primary role is to review medical documents like patient records, treatment plans, and physicians’ notes to ensure accuracy and completeness.

This includes verifying the correct usage of medical codes for diagnosis, procedures, and medications.

They work closely with healthcare professionals and medical coders to clarify any discrepancies or ambiguities in the medical documentation.

They may also need to cross-verify information with other sources, such as insurance records or patient interviews.

In addition, Medical Documentation Reviewers are responsible for ensuring the medical records are compliant with healthcare laws, regulations, and standards, including privacy and confidentiality rules.

They may also be involved in training staff on documentation procedures, conducting audits, and providing feedback to improve the quality of documentation.

In some roles, they might be asked to assist in the billing process by ensuring the accuracy and completeness of billing data before it is sent to insurance companies for reimbursement.

Overall, their role is crucial in maintaining the quality and integrity of medical records, which can impact patient care, billing, and legal issues.

 

Medical Documentation Reviewer Qualifications and Skills

A proficient Medical Documentation Reviewer should possess skills and qualifications in accordance with the job role, including:

• Medical understanding and expertise to review and interpret medical records, terminology, and diagnoses accurately
• Highly detail-oriented and analytical to identify discrepancies or inconsistencies in medical documents
• Excellent communication skills to discuss and report findings to healthcare professionals and answer any queries they might have
• Proficiency in using medical software and technology for reviewing and storing medical records
• Strong organizational skills to manage multiple medical documents and records simultaneously, ensuring accuracy and confidentiality
• Ability to work under pressure and meet deadlines while maintaining high standards of work
• Problem-solving skills to identify, investigate, and resolve any issues that may arise during the review process
• Knowledge of healthcare laws, regulations, and standards to ensure all documentation complies with relevant legal and ethical guidelines

 

Medical Documentation Reviewer Experience Requirements

Entry-level candidates for a Medical Documentation Reviewer position typically require a minimum of 1-2 years of experience in a healthcare setting, often through an internship or part-time role in medical records management or healthcare administration.

These professionals can gain on-the-job experience in roles such as Medical Records Clerk, Health Information Technician, or other healthcare-related roles.

They may also benefit from experience in medical coding and billing, as these aspects often intersect with medical documentation review.

Candidates with more than 3 years of experience often develop their skills and knowledge in roles such as Medical Records Coordinator or Health Information Manager.

They may possess a broader understanding of the regulations and compliance issues related to medical documentation.

Those with more than 5 years of experience may have some leadership experience, having overseen a team of medical records personnel or healthcare administrators.

They may be ready for a supervisory or managerial role within medical documentation review, and are expected to be well-versed in healthcare regulations, medical terminology, and Electronic Health Records (EHR) systems.

 

Medical Documentation Reviewer Education and Training Requirements

Medical Documentation Reviewers typically possess a bachelor’s degree in health information management, nursing or a related field.

An essential part of their training involves understanding the medical terminology and coding, knowledge of healthcare regulations, and the ability to read and interpret patient records and medical reports.

Some positions may require a certification, such as the Registered Health Information Technician (RHIT) or Certified Professional Coder (CPC), which are offered by organizations like the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders (AAPC).

In certain cases, especially for more specialized roles, employers may prefer candidates with a master’s degree in health informatics, health information management, or a closely related field.

Continuing education is essential in this role to keep up with changes in healthcare laws and regulations.

Many professionals opt for additional certifications and training throughout their career to broaden their skills and increase their opportunities.

Experience in the healthcare sector, especially in medical coding and documentation, is highly preferred for this role.

 

Medical Documentation Reviewer Salary Expectations

A Medical Documentation Reviewer can expect to earn an average salary of $37,800 (USD) per year.

However, the actual earnings can fluctuate based on factors such as experience, certifications, the complexity of tasks handled, and geographical location.

 

Medical Documentation Reviewer Job Description FAQs

What skills does a Medical Documentation Reviewer need?

A Medical Documentation Reviewer requires strong attention to detail, the ability to understand complex medical terminology, and excellent written and verbal communication skills.

They should also have a good knowledge of medical coding, healthcare regulations, and computer systems.

Strong analytical skills and the ability to identify patterns, discrepancies, and potential issues are also important in this role.

 

Do Medical Documentation Reviewers need a specific degree?

Medical Documentation Reviewers typically need a degree in health information management or a related field.

Some roles may also require a certification such as the Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) credential.

Furthermore, a background in nursing or medical coding can be advantageous for understanding complex medical records.

 

What should you look for in a Medical Documentation Reviewer resume?

Aside from a relevant degree and certification, look for experience with medical coding, patient record management, and healthcare regulations.

Knowledge of electronic health records (EHR) systems is a must.

Evidence of strong analytical skills, attention to detail, and excellent written and verbal communication are also important.

 

What qualities make a good Medical Documentation Reviewer?

A good Medical Documentation Reviewer is meticulous, objective, and possesses strong analytical skills.

They should be able to manage large amounts of data, and have the ability to identify inconsistencies or inaccuracies in medical records.

A successful reviewer must also have a good understanding of medical terminology, medical coding, and healthcare regulations.

 

Is it difficult to hire Medical Documentation Reviewers?

The challenge in hiring Medical Documentation Reviewers is finding professionals who not only have the necessary certifications but also have a deep understanding of medical terminology and regulations.

This role requires a high level of accuracy and diligence, thus finding the right fit can be challenging.

As an employer, offering continued education and a supportive work environment can help attract qualified candidates.

 

Conclusion

There you have it.

Today, we’ve unveiled the true essence of being a medical documentation reviewer.

Surprised?

It’s not just about scanning documents.

It’s about orchestrating healthcare accuracy, one medical record at a time.

Armed with our comprehensive medical documentation reviewer job description template and insightful examples, you’re ready for the next step.

But why limit yourself?

Delve further with our job description generator. It’s your ultimate tool for crafting precise job listings or refining your resume to absolute perfection.

Remember:

Every medical record is a piece of a larger healthcare puzzle.

Let’s solve that puzzle. Together.

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