About the position

This is a fully remote consulting opportunity for experienced inpatient Medical Coders to contribute their expertise to advanced AI training and evaluation initiatives. The role involves reviewing and annotating inpatient medical records, validating diagnosis and procedure codes, assessing clinical documentation and coding-related data quality, and applying established coding standards. Prior experience with AI training projects is not required. The work focuses on ICD-10-CM and ICD-10-PCS code assignment, diagnosis sequencing, Present on Admission (POA) indicators, MS-DRG validation, CC/MCC classification, hospital-acquired conditions, and inpatient coding guidelines. Deliverables include structured coding reviews, validated annotations, coding accuracy assessments, and written technical feedback. Engagement is freelance/contract, remote within the United States, and pays \$50–\$70 per hour. The posting states that 100 openings are available.

Responsibilities

• Review and annotate inpatient medical records, including admission notes, progress notes, consultation reports, and discharge summaries.
• Analyze operative reports, laboratory results, imaging findings, and other clinical documentation relevant to coding.
• Assign and validate ICD-10-CM diagnosis codes and ICD-10-PCS inpatient procedure codes.
• Identify principal and secondary diagnoses and evaluate diagnosis sequencing according to inpatient coding guidelines.
• Apply appropriate Present on Admission (POA) indicators.
• Identify incomplete, ambiguous, or inconsistent clinical information affecting coding accuracy.
• Validate that coding annotations reflect documented conditions, procedures, and patient encounters.
• Evaluate MS-DRG assignments and their consistency with documented diagnoses and procedures.
• Identify CCs, MCCs, hospital-acquired conditions, and relevant patient safety indicators.
• Apply UHDDS definitions, Official Coding Guidelines, AHA Coding Clinic guidance, and applicable inpatient coding conventions.
• Review coding-related AI training data for accuracy, completeness, and consistency with applicable standards.
• Prepare structured written feedback explaining coding discrepancies and recommended corrections.
• Communicate coding decisions and documentation requirements to project stakeholders.
• Collaborate with technical and operational teams to resolve coding ambiguities and clarify evaluation requirements.
• Recommend improvements to coding reliability, medical record annotations, workflows, and AI evaluation methodologies.
• Maintain accuracy, data integrity, and documentation quality across assigned deliverables.

Requirements

• Active AHIMA Certified Coding Specialist (CCS) or AAPC Certified Inpatient Coder (CIC) credential.
• Strong professional experience in inpatient medical coding and clinical documentation review.
• Advanced knowledge of ICD-10-CM diagnosis coding and ICD-10-PCS procedure coding.
• Expertise in MS-DRG assignment and inpatient classification methodology.
• Experience identifying principal and secondary diagnoses and applying diagnosis sequencing rules.
• Strong understanding of Present on Admission (POA) indicators.
• Familiarity with CC/MCC identification and its application to MS-DRG validation.
• Working knowledge of UHDDS definitions and inpatient coding conventions.
• Experience interpreting the ICD-10-CM/PCS Official Guidelines for Coding and Reporting.
• Familiarity with AHA Coding Clinic guidance and complex coding interpretations.
• Understanding of hospital-acquired conditions and relevant patient safety indicators.
• Experience reviewing admission documentation, operative reports, consultation notes, and discharge summaries.
• Ability to identify documentation inconsistencies and resolve complex coding questions.
• Experience conducting coding audits, medical record reviews, or data quality assessments.
• Access to current ICD-10-CM and ICD-10-PCS code sets, Official Coding Guidelines, and MS-DRG grouper tools.
• Strong analytical reasoning, coding accuracy, and attention to detail.
• Excellent written and verbal communication skills for explaining coding decisions and technical findings.
• Ability to collaborate effectively with clinical, coding, and technical project stakeholders.
• Strong organizational skills and ability to work independently on complex coding assignments.

Nice-to-haves

• Experience with acute care inpatient coding or teaching hospital environments.
• Exposure to specialty inpatient coding, including surgical, trauma, oncology, cardiology, or transplant cases.
• Experience with coding across multiple inpatient specialties.