Medical Records Coder

What You'll Do6

• Review clinical documentation, including progress notes, consults, lab results, and discharge summaries, to assign accurate ICD-10-CM, ICD-10-PCS, CPT, and HCPCS codes.
• Determine principal and secondary diagnoses, sequence codes per official guidelines, and apply modifiers and Present on Admission (POA) indicators when relevant.
• Follow the Official Guidelines for Coding and Reporting and AHA Coding Clinic advice while noting documentation gaps and opportunities to query providers.
• Work with project stakeholders through written and verbal channels to clarify requirements, resolve ambiguous documentation, and maintain data integrity.
• Provide detailed feedback on coding rules and complex cases to improve project workflows and help AI models better understand clinical coding.
• Confirm that all coding annotations meet current standards and best practices for accuracy and completeness.

Requirements6

• Active AHIMA Certified Coding Specialist (CCS), AAPC Certified Inpatient Coder (CIC), or AAPC Certified Professional Coder (CPC) credential.
• Solid command of ICD-10-CM, ICD-10-PCS, and CPT, with practical experience coding directly from medical records.
• Experience coding in at least one setting such as acute care, outpatient, emergency department, or physician practice.
• Ability to review and code different types of clinical documentation and handle complex coding scenarios.
• Clear written and verbal communication skills with strong attention to detail.
• Access to current ICD-10-CM, ICD-10-PCS, and CPT code sets and the Official Coding Guidelines.

Who Should Apply

Certified coders (CCS, CIC, or CPC) with hands-on experience across settings like acute care, outpatient, ED, or physician practice. You should be comfortable reviewing diverse clinical documentation and applying official coding guidelines. Strong communication and detail focus are essential for collaborating with stakeholders.

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