Scope of Work Annotate and review inpatient medical records, including admission notes, progress notes, operative reports, consults, lab and imaging results, and discharge summaries, ensuring precise ICD-10-CM and ICD-10-PCS code assignment based on documentation. Identify principal and secondary diagnoses, sequence codes according to guidelines, assign Present on Admission (POA) indicators, and validate MS-DRG assignment, including the identification of CCs and MCCs, to verify and enrich data sets. Apply inpatient-specific coding conventions, such as UHDDS definitions, ICD-10-CM/PCS Official Guidelines for Coding and Reporting, and AHA Coding Clinic guidance, while identifying hospital-acquired conditions (HACs) and patient safety indicators. Collaborate with project stakeholders using both written and verbal communication to clarify requirements, resolve documentation ambiguities, and ensure data integrity. Deliver high-quality feedback on coding guidelines and complex cases to support project workflow improvements and enhance AI model understanding. Ensure accuracy and completeness of all coding-related annotations per current best practices and coding standards. Preferred Qualifications Active AHIMA Certified Coding Specialist (CCS) or AAPC Certified Inpatient Coder (CIC) credential. Thorough expertise in ICD-10-CM, ICD-10-PCS, and MS-DRG methodology with hands-on inpatient coding experience. Experience coding in diverse inpatient settings, such as acute care, teaching hospitals, specialty units, surgical, trauma, oncology, cardiology, and transplant cases. Proficiency in reviewing and coding various types of clinical documentation and addressing complex coding challenges. Strong written and verbal communication skills, demonstrating meticulous attention to detail and clarity. Access to current ICD-10-CM and ICD-10-PCS code sets, Official Coding Guidelines, and MS-DRG grouper tools. Posted 4 days ago

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