This role is for one of our clients
Pay: 50–70/hour
Role Type: Contractor
Location: US – Remote
We are seeking experienced Medical Coders with CCS or CIC certification to contribute their expertise to a project focused on improving the accuracy, reliability, and clinical understanding of advanced artificial intelligence systems.
In this role, you will apply your inpatient medical coding knowledge to annotate, review, and validate clinical documentation using established coding standards and guidelines. You will work with complex inpatient medical records, assign accurate ICD-10-CM and ICD-10-PCS codes, determine appropriate diagnosis sequencing, and validate MS-DRG classifications.
Your expertise will help improve how AI systems interpret clinical documentation, recognize medical conditions, apply coding conventions, and make accurate coding-related decisions. Previous experience in AI or machine learning is not required; strong medical coding expertise and attention to detail are the primary requirements.
Requirements
Key Responsibilities
- Inpatient Medical Record Review: Review admission notes, progress notes, operative reports, consultation records, laboratory and imaging results, and discharge summaries to identify relevant diagnoses and procedures.
- ICD-10-CM and ICD-10-PCS Coding: Assign accurate diagnosis and procedure codes based on clinical documentation and current official coding guidelines.
- Diagnosis Identification and Sequencing: Identify principal and secondary diagnoses, apply appropriate sequencing rules, and ensure compliance with inpatient coding requirements.
- MS-DRG Validation: Review and validate Medicare Severity Diagnosis-Related Group (MS-DRG) assignments, including the identification of Complications or Comorbidities (CCs) and Major Complications or Comorbidities (MCCs).
- Present on Admission Assessment: Assign and validate Present on Admission (POA) indicators in accordance with applicable guidelines.
- Coding Compliance: Apply inpatient coding conventions, including the Uniform Hospital Discharge Data Set (UHDDS) definitions, ICD-10-CM/PCS Official Guidelines for Coding and Reporting, and relevant AHA Coding Clinic guidance.
- Clinical Quality and Safety Review: Identify hospital-acquired conditions (HACs), patient safety indicators, and other coding-relevant clinical details where applicable.
- AI Data Annotation and Evaluation: Annotate and validate clinical data to support AI training, model evaluation, and the development of more accurate automated coding systems.
- Complex Case Analysis: Investigate ambiguous documentation, resolve coding challenges, and provide evidence-based recommendations for complex inpatient cases.
- Quality Assurance and Feedback: Deliver structured feedback on coding accuracy, guideline interpretation, and complex scenarios to improve annotation quality and project workflows.
- Stakeholder Collaboration: Communicate with project stakeholders to clarify requirements, resolve documentation discrepancies, and maintain data integrity.
Required Qualifications
- Active AHIMA Certified Coding Specialist (CCS) or AAPC Certified Inpatient Coder (CIC) certification.
- Strong hands-on experience in inpatient medical coding and clinical documentation review.
- Thorough understanding of ICD-10-CM and ICD-10-PCS coding systems.
- Proficiency in MS-DRG methodology, diagnosis sequencing, and principal diagnosis selection.
- Knowledge of POA indicators, CCs, MCCs, UHDDS definitions, and applicable inpatient coding guidelines.
- Ability to interpret complex clinical documentation and accurately translate medical information into appropriate codes.
- Familiarity with AHA Coding Clinic guidance and current official coding standards.
- Strong analytical, critical-thinking, and problem-solving skills.
- Excellent written and verbal communication skills, with meticulous attention to detail.
- Ability to work independently, follow detailed instructions, and consistently deliver accurate, high-quality coding annotations.
Must-Have Skills
- Medical Coding
- CCS or CIC Certification
- Inpatient Medical Coding
- ICD-10-CM
- ICD-10-PCS
- MS-DRG Methodology
- Principal and Secondary Diagnosis Coding
- Diagnosis Sequencing
- Present on Admission (POA) Indicators
- Clinical Documentation Review
- Coding Guidelines and Compliance
Good-to-Have Skills
- AHA Coding Clinic Interpretation
- UHDDS Definitions
- Hospital-Acquired Conditions (HACs)
- Patient Safety Indicators
- CC and MCC Identification
- Complex Surgical and Inpatient Case Coding
- Acute Care and Teaching Hospital Experience
- Trauma, Oncology, Cardiology, and Transplant Coding
- Medical Data Annotation and Quality Assurance
- AI Training and Model Evaluation
Preferred Experience
Candidates with experience coding inpatient records across acute care hospitals, teaching hospitals, surgical units, trauma services, oncology, cardiology, or transplant services will be particularly well suited for this role.
Experience handling complex clinical cases, reviewing detailed operative documentation, resolving coding ambiguities, and validating DRG assignments will be an advantage.
Candidates should also have access to current ICD-10-CM and ICD-10-PCS code sets, official coding guidelines, and appropriate MS-DRG grouper tools to support accurate and consistent coding decisions.