Certified Inpatient Medical Coder

Role Title: Certified Inpatient Medical Coder

Role Type: Contractor

Location: United States, Remote

Our client is engaging a Certified Inpatient Medical Coder to contribute to a customer's project focused on enhancing medical data accuracy and integrity. In this role, you'll apply your expertise to help train next-generation AI systems. Your work will shape how models learn, reason, and perform through high-quality, real-world input.

Scope of Work

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