Medical Records Auditor Job Description [Updated for 2025]

In the era of digitized healthcare, the role of a medical records auditor is more critical than ever.

As the medical field continues to evolve, so does the demand for experts who can meticulously review, analyze, and secure our health records.

But let’s delve deeper: What’s really expected from a medical records auditor?

Whether you are:

• A job seeker trying to comprehend the intricacies of this role,
• A hiring manager looking to identify the perfect candidate,
• Or simply curious about the ins and outs of medical records auditing,

You’ve come to the right place.

Today, we present a customizable medical records auditor job description template, designed for seamless posting on job boards or career sites.

Let’s dive right into it.

Medical Records Auditor Duties and Responsibilities

Medical Records Auditors are responsible for reviewing, examining, and verifying the accuracy and completeness of medical records in compliance with healthcare regulations and standards.

Their duties and responsibilities include:

• Reviewing and examining medical records for accuracy and completeness
• Ensuring that all required documentation is present in each patient’s medical record
• Verifying that medical coding and billing procedures are correctly applied
• Identifying potential issues of non-compliance with regulations and standards
• Preparing detailed reports of audit findings and making recommendations for corrective actions
• Collaborating with medical staff to educate and advise on proper documentation and coding practices
• Keeping abreast of changes in medical coding and billing regulations
• Assisting in the development and implementation of policies and procedures to improve the medical record system

 

Medical Records Auditor Job Description Template

Job Brief

We are seeking a diligent Medical Records Auditor to monitor and improve the quality of our medical records.

The Medical Records Auditor will be responsible for reviewing medical records to ensure compliance with legal and regulatory requirements, as well as institutional policies.

The ideal candidate has a strong understanding of medical terminology, coding systems, and healthcare regulations.

The main goal will be to maintain high levels of accuracy and consistency in our medical records.

 

Responsibilities

• Review and analyze medical records for accuracy and completeness
• Ensure all patient records are coded accurately in accordance with coding guidelines
• Identify, report, and help rectify any inconsistencies or errors
• Work with healthcare providers to verify the information in the records
• Monitor and ensure compliance with health and legal regulations
• Maintain confidentiality of all patient information
• Stay up-to-date with changes in medical coding and relevant laws
• Recommend changes in procedures to improve record management

 

Qualifications

• Proven work experience as a Medical Records Auditor or similar role
• Knowledge of medical terminology, ICD-10, and CPT codes
• Familiarity with health information management (HIM) systems
• Knowledge of healthcare regulations, medical laws, and ethical standards
• Strong analytical and problem-solving skills
• Excellent attention to detail
• Ability to maintain confidentiality
• Associate’s or Bachelor’s degree in Health Information Management or a related field
• Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification is a plus

 

Benefits

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

 

Additional Information

• Job Title: Medical Records Auditor
• Work Environment: This is largely a sedentary role that requires reviewing and verifying medical records. Office setting, with some potential for remote work.
• Reporting Structure: Reports to the Health Information Manager or Compliance Officer.
• Salary: Salary is based upon candidate experience and qualifications, as well as market and business considerations.
• Pay Range: $45,000 minimum to $75,000 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 Records Auditor Do?

Medical Records Auditors are critical members of healthcare administration teams who review and evaluate the accuracy of patient records.

Their primary role is to verify the accuracy, completeness, and compliance of patient medical records, ensuring they adhere to relevant laws and regulations, such as HIPAA.

They are responsible for auditing patient records to identify any coding errors, potential fraud, or inconsistencies that could affect patient care or cause financial or legal issues for healthcare providers.

Medical Records Auditors also work closely with other healthcare professionals, including doctors, nurses, and medical coders, to clarify and rectify any discrepancies found in medical records.

Part of their job might include education and training for healthcare staff on the proper methods of record keeping, especially as it relates to coding and billing practices.

They also provide detailed reports on audit findings and suggest improvements to enhance the accuracy and quality of medical record keeping.

Their role is crucial in ensuring the integrity of patient data, which is fundamental to high-quality healthcare delivery and the overall financial health of the healthcare institution.

 

Medical Records Auditor Qualifications and Skills

A Medical Records Auditor should possess a distinct set of qualifications and skills to effectively perform the duties of the job, such as:

• A strong understanding of healthcare information management, as well as medical coding systems, to accurately review and assess medical records.
• Attention to detail to ensure all information in medical records is accurate, complete, and compliant with regulations, standards, and laws.
• Strong analytical skills to identify any discrepancies or inconsistencies in medical documentation and to determine the accuracy of coding and billing practices.
• Excellent communication skills to clearly convey audit findings to healthcare providers, administrators, and other relevant stakeholders, and to provide recommendations for improvements or corrective actions when necessary.
• Working knowledge of healthcare regulations, including the Health Insurance Portability and Accountability Act (HIPAA), to ensure all reviewed records comply with legal requirements.
• Problem-solving skills to identify issues that may impact the quality or integrity of medical records and to develop and implement effective solutions.
• Ability to use medical software and computer systems to access and review electronic health records (EHRs).
• Experience in medical billing and coding, as well as a certification in health information management or a related field, can provide a solid foundation for a career as a Medical Records Auditor.

 

Medical Records Auditor Experience Requirements

Medical Records Auditors are typically required to have at least 2 to 3 years of experience in medical coding, billing, or medical records review.

This can often be gained through working in roles like Medical Records Technician, Medical Coder, Billing Specialist, or similar roles in a healthcare setting.

Entry-level candidates may have experience through internships or part-time roles in a healthcare setting, often involving tasks related to medical records, billing, or coding.

Candidates with more than 3 years of experience are often expected to have developed their technical skills and knowledge in medical records management, coding practices, and regulatory compliance.

They may also have experience in conducting audits and providing feedback to improve documentation accuracy.

Those with more than 5 years of experience may have some leadership experience in their background and may be ready for a managerial or supervisory position.

They may also hold credentials as a Certified Professional Coder (CPC) or Certified Coding Specialist (CCS), which showcase their advanced expertise and commitment to the field.

 

Medical Records Auditor Education and Training Requirements

Medical Records Auditors typically require a bachelor’s degree in health information management or a related field.

They are also expected to have a strong background in medical coding systems, healthcare laws and regulations, and auditing techniques.

Prior experience in a healthcare setting is often beneficial.

Many employers require Medical Records Auditors to have professional certification, such as the Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) credential.

To become certified, candidates must pass a comprehensive exam that tests their understanding of medical terminology, anatomy and physiology, and the guidelines for medical coding, billing, and auditing.

In addition to their initial education and certification, Medical Records Auditors should engage in continuous learning to stay up-to-date with changes in healthcare legislation and technology.

Some auditors may choose to pursue advanced degrees or additional certifications to specialize in a particular area of medical auditing or to enhance their career advancement opportunities.

Master’s degrees in health informatics, healthcare administration, or a related field can provide auditors with a deeper understanding of the healthcare industry and the complex systems used to manage patient information.

 

Medical Records Auditor Salary Expectations

A Medical Records Auditor earns an average salary of $57,995 (USD) per year.

The actual salary may vary based on factors such as years of experience, certifications, the size of the employer, and the location of employment.

 

Medical Records Auditor Job Description FAQs

What skills does a Medical Records Auditor need?

Medical Records Auditors should possess excellent attention to detail to identify errors in medical records and coding.

They should have a strong understanding of medical terminology, coding systems, and healthcare billing practices.

Strong analytical, communication, and computer skills are also essential.

 

Do Medical Records Auditors need a degree?

Yes, Medical Records Auditors typically need a degree in Health Information Management or a related field.

They also need certification in health information management, such as Registered Health Information Technician (RHIT) or Certified Professional Coder (CPC).

Some employers may require additional auditing certifications.

 

What should you look for in a Medical Records Auditor resume?

When reviewing a Medical Records Auditor resume, look for a degree in Health Information Management or a related field, as well as relevant certifications.

Previous experience in medical coding, billing, or auditing is also important.

Proficiency in using medical billing software and a strong understanding of medical terminology and coding systems should be evident.

 

What qualities make a good Medical Records Auditor?

A good Medical Records Auditor is highly organized and detail-oriented, ensuring they can accurately review and correct medical records.

They must be analytical to identify patterns of errors or fraud.

Good communication skills are important, as they often need to explain their findings to healthcare providers or management.

 

What are the daily duties of a Medical Records Auditor?

Medical Records Auditors spend most of their day reviewing medical records for accuracy and compliance with billing and coding standards.

They identify and correct errors, and may be involved in training staff on correct coding practices.

They often interact with healthcare providers, insurance companies, and management to discuss audit findings and recommendations.

 

Conclusion

And there you have it.

Today, we’ve uncovered the true essence of being a Medical Records Auditor.

Surprise, surprise!

It’s not just about analyzing health records.

It’s about ensuring the accuracy and completeness of these records, one patient at a time.

With our user-friendly Medical Records Auditor job description template and real-world examples, you’re now ready to make your next move.

But why stop there?

Dig deeper with our job description generator. It’s your stepping stone to perfecting job listings or tailoring your resume to a T.

Remember:

Every patient’s record is a piece of a larger health puzzle.

Let’s piece that puzzle together. Together.

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