Medical Coder, ICD-10, Clinical Documentation

This is a fully remote position, open to applicants in New York.

📋 Description

• Assess clinical documentation for accuracy and completeness in coding.

• Determine if the assigned codes are substantiated by the underlying documentation.

• Detect inconsistencies in coding, omissions, unsupported assignments, and gaps in documentation.

• Utilize current ICD-10 coding standards for the assigned cases.

• Analyze clinical notes, summaries, and supporting documents.

• Ensure alignment between clinical documentation and the assigned diagnosis or procedure codes.

• Identify cases that need clarification or additional documentation.

• Document clinical records following specific project guidelines.

• Classify documentation and coding issues while providing clear written explanations.

• Assess generated clinical notes and summaries against established coding and documentation standards.

• Review multilingual clinical materials and pinpoint linguistic discrepancies that may impact clinical or coding interpretation.

• Offer professional insights to enhance coding and documentation review guidelines.

• Pose clarifying questions and assist in advancing documentation and annotation standards.

⛳️ Requirements

• Valid certification in at least one of the following: CCDS, CHC, CCS, CPC.

• Practical experience with ICD-10 coding.

• Currently employed in medical coding, clinical documentation improvement (CDI), or a closely related clinical documentation position.

• Based in the United States.

• Proficient in English at an advanced C1 level or higher.

• Advanced C1-level or higher proficiency in speaking, listening, and writing in at least one additional language.

• Strong comprehension of clinical documentation and coding integrity.

• Capable of consistently adhering to detailed review and annotation guidelines.

• Excellent written communication skills and meticulous attention to detail.

• Additional certifications such as CRC, CDIP, or similar credentials are a plus.

• Familiarity with Epic is preferred.

• Experience with HCC or risk-adjustment coding is beneficial.

• Prior experience in clinical annotation or model evaluation is preferred.

• Work must be performed without utilizing confidential or proprietary information from any employer, client, healthcare organization, institution, patient, or other third party.

• H1-B and STEM OPT support is not available for this position.

🏝️ Benefits

• Part-time independent contractor position.

• Fully remote work within the United States.

• Minimum commitment of 10 hours per week.

• Flexible scheduling options.

• Projects may be extended, shortened, or concluded based on project requirements and performance.