Medical Coder, CCS, CIC

This is a fully remote position, open to applicants in United States.

📋 Description

• Examine admission notes, progress notes, operative reports, consultation records, laboratory and imaging results, as well as discharge summaries.

• Accurately assign ICD-10-CM and ICD-10-PCS diagnosis and procedure codes.

• Determine principal and secondary diagnoses while applying the appropriate sequencing rules.

• Review and confirm MS-DRG assignments, including the identification of CC and MCC.

• Assign and verify Present on Admission (POA) indicators.

• Utilize UHDDS definitions, official ICD-10-CM/PCS guidelines, and AHA Coding Clinic standards.

• Identify hospital-acquired conditions, patient safety indicators, and other clinically relevant coding details.

• Annotate and validate clinical data for AI training and model assessment.

• Investigate unclear documentation and address complex inpatient coding issues.

• Provide evidence-based recommendations and structured feedback to enhance annotation quality and streamline project workflows.

• Engage with stakeholders to clarify requirements, resolve documentation inconsistencies, and uphold data integrity.

⛳️ Requirements

• Current AHIMA Certified Coding Specialist (CCS) or AAPC Certified Inpatient Coder (CIC) certification.

• Extensive hands-on experience in inpatient medical coding and clinical documentation assessment.

• Comprehensive knowledge of ICD-10-CM and ICD-10-PCS coding systems.

• Proficiency in MS-DRG methodology, diagnosis sequencing, and selection of principal diagnoses.

• Familiarity with POA indicators, CCs, MCCs, UHDDS definitions, and relevant inpatient coding guidelines.

• Capability to interpret complex clinical documentation and accurately convert medical information into appropriate codes.

• Knowledge of AHA Coding Clinic guidance and the latest official coding standards.

• Strong analytical, critical thinking, and problem-solving abilities.

• Excellent written and verbal communication skills, with a keen eye for detail.

• Ability to work independently, adhere to detailed instructions, and consistently provide precise, high-quality coding annotations.

• Essential 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 suitable MS-DRG grouper tools.

🏝️ Benefits

• Competitive salary and performance-based incentives.

• Comprehensive health, dental, and vision insurance.

• Opportunities for professional development and continuing education.

• Flexible work schedules and remote work options.

• Supportive and collaborative work environment.