Certified Inpatient Coder

Role Title: Certified Inpatient Coder

Role Type: Contractor

Location: United States, Remote

Scope of Work

1. Review and analyze inpatient medical records to ensure accurate ICD-10-CM and ICD-10-PCS coding in alignment with current guidelines and best practices.
2. Review clinical documentation for accuracy, completeness, and coding integrity.
3. Identify principal and secondary diagnoses, sequence codes per the Official Guidelines, and assign Present on Admission (POA) indicators.
4. Validate MS-DRG assignment, including identification of CCs and MCCs, and flag hospital-acquired conditions (HACs) and patient safety indicators.
5. Evaluate AI-generated clinical notes and summaries against real-world documentation and coding standards.
6. Code AI-generated diagnostic and procedural information from the record using ICD-10-CM and ICD-10-PCS classification systems.
7. Identify and resolve discrepancies in diagnosis and procedure coding, ensuring the integrity of record abstraction and data capture.
8. Provide clear written feedback on coding errors and complex cases to improve model performance.

Preferred Qualifications

1. Active certification in one of the following: CIC or CCS, or other coding certification through AHIMA and AAPC (e.g., RHIA, RHIT, COC).
2. Inpatient ICD-10-CM/PCS coding experience.
3. Access to up-to-date official ICD-10-CM/PCS coding books and Coding Clinic guidance.
4. Currently working in inpatient medical coding, clinical documentation improvement, or a closely related documentation role.
5. Availability of at least 10 hours per week.