Medical Records Coder

• Annotate and review medical records, including encounter notes, progress notes, operative reports, consults, lab and imaging results, and discharge summaries, ensuring precise ICD-10-CM, ICD-10-PCS, CPT, and HCPCS code assignment based on documentation.
• Identify principal and secondary diagnoses, sequence codes according to guidelines, and assign modifiers and Present on Admission (POA) indicators where applicable, to verify and enrich data sets.
• Apply coding conventions and payer-neutral best practices, including the Official Guidelines for Coding and Reporting and AHA Coding Clinic guidance, while flagging documentation gaps and query opportunities.
• 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.

• Domain knowledge is what matters.

• Active AHIMA Certified Coding Specialist (CCS), AAPC Certified Inpatient Coder (CIC), or AAPC Certified Professional Coder (CPC) credential.
• Thorough expertise in ICD-10-CM, ICD-10-PCS, and CPT, with hands-on experience coding from medical records.
• Experience coding across settings such as acute care, outpatient, emergency department, and physician practice.
• 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, ICD-10-PCS, and CPT code sets and Official Coding Guidelines.

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

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