Remote | Certified Inpatient Coder

We are sharing a specialised remote consulting opportunity for experienced US-based Certified Inpatient Coders with strong expertise in inpatient medical coding, ICD-10-CM and ICD-10-PCS classification systems, clinical documentation review, and MS-DRG assignment to contribute their professional knowledge to advanced AI training and evaluation initiatives.

Selected professionals will review complex inpatient medical records, validate diagnosis and procedure coding, assess clinical documentation accuracy, and evaluate AI-generated medical information against established coding standards. The work combines practical inpatient coding expertise with clinical data interpretation, regulatory guideline application, structured quality assessment, and detailed technical feedback to help improve the accuracy, consistency, and reliability of AI systems operating across healthcare coding and clinical documentation workflows.

Key Responsibilities

Inpatient Medical Record Review & Coding Analysis

• Review and analyse inpatient medical records to ensure accurate diagnosis and procedure coding
• Apply current ICD-10-CM and ICD-10-PCS classification guidelines to complex inpatient clinical documentation
• Evaluate the complete inpatient admission to identify relevant diagnoses, procedures, and clinical circumstances
• Review clinical documentation for accuracy, completeness, consistency, and alignment with established coding standards
• Apply professional coding judgement to identify important clinical details, documentation requirements, and classification considerations

Diagnosis Sequencing & ICD-10 Classification

• Identify principal and secondary diagnoses using the Official Guidelines for Coding and Reporting
• Apply appropriate ICD-10-CM codes based on documented clinical conditions and relevant inpatient coding conventions
• Assign ICD-10-PCS procedure codes accurately according to documented inpatient procedures
• Evaluate diagnosis sequencing decisions and assign Present on Admission (POA) indicators where applicable
• Identify discrepancies in diagnostic or procedural classification and explain appropriate coding corrections

MS-DRG Validation & Clinical Documentation Integrity

• Validate Medicare Severity Diagnosis Related Group (MS-DRG) assignments using relevant diagnosis and procedure information
• Assess the impact of complications and comorbidities (CCs) and major complications and comorbidities (MCCs) on DRG classification
• Review inpatient records for hospital-acquired conditions (HACs) and relevant patient safety indicators
• Evaluate clinical documentation for coding completeness, accuracy, and consistency with official coding requirements
• Identify documentation gaps, conflicting information, and coding issues affecting record abstraction and data integrity

AI Training & Clinical Coding Evaluation

• Review and validate AI-generated clinical notes, medical summaries, diagnostic information, and procedural documentation
• Compare AI-generated coding recommendations with established ICD-10-CM and ICD-10-PCS guidelines
• Identify inaccurate diagnosis assignments, procedural coding errors, and incomplete clinical interpretations
• Evaluate AI-generated medical information for consistency with realistic inpatient documentation and coding standards
• Provide detailed written feedback explaining coding errors, complex classification decisions, and opportunities for improved model performance

Coding Quality Assurance & Technical Feedback

• Review inpatient coding outputs for accuracy, completeness, and compliance with current coding guidelines
• Identify and resolve discrepancies in diagnosis and procedure coding to support accurate clinical data capture
• Produce clear coding explanations, structured documentation assessments, and detailed quality review feedback
• Apply official coding references and AHA Coding Clinic guidance when evaluating complex inpatient scenarios
• Support continuous improvement of coding accuracy, medical data integrity, and specialised AI evaluation deliverables

Ideal Profile

• Active professional coding certification such as Certified Inpatient Coder (CIC), Certified Coding Specialist (CCS), or another relevant AHIMA or AAPC credential
• Additional qualifications such as RHIA, RHIT, or COC may also be considered
• Substantial hands-on experience in inpatient medical coding, clinical documentation improvement, or a closely related healthcare coding function
• Strong command of ICD-10-CM diagnosis coding and ICD-10-PCS inpatient procedure coding
• Demonstrated ability to review complex…