Remote review of inpatient records to check ICD-10 coding and DRG assignment, and to grade AI-generated clinical notes against coding standards. It suits certified inpatient medical coders who know the official guidelines and can write clear feedback on errors.
Sobre la vacante
Location: United States, Remote
micro1 is engaging a Certified Inpatient Medical Coder to contribute to a customer's project focused on enhancing medical data accuracy and integrity. In this role, you'll apply your expertise to help train next-generation AI systems. Your work will shape how models learn, reason, and perform through high-quality, real-world input.
Scope of Work
- Review and analyze inpatient medical records to ensure accurate ICD-10-CM and ICD-10-PCS coding in alignment with current guidelines and best practices.
- Review clinical documentation for accuracy, completeness, and coding integrity.
- Identify principal and secondary diagnoses, sequence codes per the Official Guidelines, and assign Present on Admission (POA) indicators.
- Validate MS-DRG assignment, including identification of CCs and MCCs, and flag hospital-acquired conditions (HACs) and patient safety indicators.
- Evaluate AI-generated clinical notes and summaries against real-world documentation and coding standards.
- Code AI-generated diagnostic and procedural information from the record using ICD-10-CM and ICD-10-PCS classification systems.
- Identify and resolve discrepancies in diagnosis and procedure coding, ensuring the integrity of record abstraction and data capture.
- Provide clear written feedback on coding errors and complex cases to improve model performance.
Preferred Qualifications
- Active certification in one of the following: CIC or CCS, or other coding certification through AHIMA and AAPC (e.g., RHIA, RHIT, COC).
- Inpatient ICD-10-CM/PCS coding experience.
- Access to up-to-date official ICD-10-CM/PCS coding books and Coding Clinic guidance.
- Currently working in inpatient medical coding, clinical documentation improvement, or a closely related documentation role.
- Availability of at least 10 hours per week.
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