Job Description: Inpatient Coder (CCS)

Role Type: Contractor
Location: United States (Remote)

Job Summary

We are seeking experienced Inpatient Coders to support a project focused on improving clinical coding accuracy, medical documentation quality, and healthcare data integrity.

In this role, you will apply your medical coding expertise to review inpatient medical records, validate clinical documentation, assess AI-generated clinical content, and ensure coding accuracy in accordance with established industry standards. Your knowledge will help improve the reliability and quality of AI systems used in healthcare.

Scope of Work

1. Review and analyze inpatient medical records to ensure accurate ICD-10 and applicable CPT/HCPCS coding in accordance with current guidelines and industry best practices.
2. Evaluate clinical documentation for accuracy, completeness, consistency, and coding integrity.
3. Review AI-generated clinical notes and summaries against source medical records and established documentation and coding standards.
4. Validate and assign appropriate diagnostic and procedural codes using applicable ICD-10-CM, ICD-10-PCS, and CPT/HCPCS classification systems.
5. Identify and resolve discrepancies in diagnosis and procedure coding to maintain accurate record abstraction and data capture.
6. Enter and validate AI-generated patient information in computerized inpatient and outpatient medical record databases, following established workflows and quality standards.

Preferred Qualifications

1. Active certification in one or more of the following: Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), Certified Outpatient Coder (COC), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or another recognized AHIMA or AAPC coding certification.
2. Hands-on experience with ICD-10 coding and medical record review.
3. Access to current official ICD-10 and CPT coding references, along with Evaluation and Management (E/M) coding guidelines.
4. Current employment or recent experience in medical coding, clinical documentation improvement (CDI), or a closely related healthcare documentation role.
5. Availability to contribute at least 10 hours per week.
6. Strong attention to detail and the ability to identify coding discrepancies and documentation gaps.
7. Ability to work independently, follow established coding guidelines, and maintain high standards of accuracy and quality.

Ideal Candidate Profile

The ideal candidate is a certified medical coding professional with practical experience reviewing inpatient medical records, applying coding guidelines, and validating clinical documentation. They demonstrate strong analytical skills, coding accuracy, and the ability to evaluate AI-generated healthcare content against real-world medical records and established coding standards.