About This Role
The Medical Coder will apply their expertise to a specialized project focused on improving next-generation AI systems by reviewing, annotating, and validating inpatient medical records. This opportunity suits an experienced, certification-qualified medical coder with strong clinical coding knowledge and attention to detail, with no prior AI experience required.
Responsibilities
- Review and annotate inpatient medical records, including admission notes, progress notes, operative reports, consultation notes, laboratory and imaging results, and discharge summaries
- Assign accurate ICD-10-CM and ICD-10-PCS codes based on clinical documentation
- Identify principal and secondary diagnoses and sequence codes according to official coding guidelines
- Assign Present on Admission (POA) indicators and validate MS-DRG assignments, including Complications/Comorbidities (CCs) and Major Complications/Comorbidities (MCCs)
- Apply inpatient coding standards, including UHDDS definitions, official ICD-10-CM/PCS guidelines, and AHA Coding Clinic guidance
- Identify hospital-acquired conditions (HACs) and relevant patient safety indicators
- Review complex cases, identify documentation ambiguities, and ensure coding accuracy and data integrity
- Collaborate with project stakeholders to clarify requirements and resolve coding-related questions
- Provide detailed feedback on coding guidelines and complex cases to improve annotation quality and workflow efficiency
- Maintain high standards of accuracy, completeness, consistency, and quality assurance
Requirements
- Active AHIMA Certified Coding Specialist (CCS) or AAPC Certified Inpatient Coder (CIC) certification
- Strong knowledge of ICD-10-CM, ICD-10-PCS, and MS-DRG methodology
- Hands-on experience in inpatient medical coding
- Proficiency in reviewing clinical documentation and handling complex coding scenarios
- Strong understanding of inpatient coding conventions, sequencing rules, and official coding guidelines
- Excellent written and verbal communication skills
- Exceptional attention to detail and commitment to data quality
- Access to current ICD-10-CM/PCS code sets, official coding guidelines, and MS-DRG grouper tools
Nice to have:
- Experience coding inpatient records across one or more of the following settings: acute care and teaching hospitals, surgical and trauma cases, oncology and cardiology, specialty units and transplant cases
Important Details
- Schedule: 20 hours per week
Application Process
- Share your updated resume along with your certification details and relevant experience for consideration
