Job Description:

• Review admission notes, progress notes, operative reports, consultation records, laboratory and imaging results, and discharge summaries
• Assign accurate ICD-10-CM and ICD-10-PCS diagnosis and procedure codes
• Identify principal and secondary diagnoses and apply appropriate sequencing rules
• Review and validate MS-DRG assignments, including CC and MCC identification
• Assign and validate Present on Admission (POA) indicators
• Apply UHDDS definitions, official ICD-10-CM/PCS guidelines, and AHA Coding Clinic guidance
• Identify hospital-acquired conditions, patient safety indicators, and other coding-relevant clinical details
• Annotate and validate clinical data for AI training and model evaluation
• Investigate ambiguous documentation and resolve complex inpatient coding challenges
• Provide evidence-based recommendations and structured feedback to improve annotation quality and project workflows
• Communicate with stakeholders to clarify requirements, resolve documentation discrepancies, and maintain data integrity

Requirements:

• 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
• Access to current ICD-10-CM and ICD-10-PCS code sets, official coding guidelines, and appropriate MS-DRG grouper tools

Benefits: