Inpatient Coder (CCS / CIC)

• 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.

• Thorough expertise in ICD-10-CM, ICD-10-PCS, and MS-DRG methodology with hands-on inpatient coding experience.
• 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.

• Active AHIMA Certified Coding Specialist (CCS) or AAPC Certified Inpatient Coder (CIC) credential.
• Experience coding in diverse inpatient settings, such as acute care, teaching hospitals, specialty units, surgical, trauma, oncology, cardiology, and transplant cases.

Also listed: written and verbal communication, attention to detail.

Project and contracting process: the hiring partner. Applications continue on the provider's website.