Certified Inpatient Coder - Remote

YO AI Labs; New York (NY); Remote; USD 41,000 - 76,000; Part time

Job summary

YO AI Labs seeks an experienced Certified Inpatient Coder (contractor) to support a project improving coding accuracy and AI-driven clinical documentation. You will review records, validate diagnoses and procedures, assess AI-generated notes, and ensure compliance with official guidelines.

Ideal candidates hold active CIC/CCS/RHIA/RHIT/COC certifications, with hands-on inpatient coding experience and the ability to contribute at least 10 hours per week.

Qualifications

• Active certification in one or more AHIMA or AAPC coding certifications.
• Hands-on experience with inpatient ICD-10-CM and ICD-10-PCS coding.
• Access to up-to-date official ICD-10-CM/PCS coding references and Coding Clinic guidance.
• Current experience in inpatient medical coding, CDI, or related healthcare documentation role.
• Availability to contribute at least 10 hours per week.
• Strong knowledge of inpatient coding guidelines, diagnosis sequencing, POA indicators, and MS-DRG assignment.
• Excellent analytical skills and attention to detail.
• Ability to work independently and follow established guidelines.

Responsibilities

• Review inpatient records to ensure accurate ICD-10-CM/PCS coding per guidelines.
• Evaluate clinical documentation for accuracy, completeness, and consistency.
• Identify principal/secondary diagnoses and POA indicators.
• Validate MS-DRG assignments and flag CCs/MCCs and HACs.
• Evaluate AI-generated notes against source records and standards.
• Assign codes using ICD-10-CM/PCS.
• Identify and resolve discrepancies to maintain data integrity.
• Provide clear written feedback on coding errors and gaps to improve AI model performance.

Skills

ICD-10-CM/PCS coding

Clinical documentation improvement

Analytical skills

Attention to detail

Written feedback

Independent work

Education

CIC

CCS

RHIA

RHIT

COC

Tools

ICD-10-CM/PCS references

Job description

Job Description

Job Description: Certified Inpatient Coder

Role Type: Contractor
Location: United States (Remote)

Job Summary

We are seeking experienced Certified Inpatient Coders to support a project focused on improving medical coding accuracy, clinical documentation quality, and healthcare data integrity.

In this role, you will apply your expertise in inpatient coding to review medical records, validate diagnosis and procedure codes, assess AI-generated clinical documentation, and ensure compliance with official coding guidelines. Your feedback will help improve the accuracy and reliability of AI systems used in healthcare.

Scope of Work

1. Review and analyze inpatient medical records to ensure accurate ICD-10-CM and ICD-10-PCS coding in accordance with current official guidelines and industry best practices.
2. Evaluate clinical documentation for accuracy, completeness, consistency, and coding integrity.
3. Identify principal and secondary diagnoses, sequence codes according to the Official Guidelines for Coding and Reporting, and assign Present on Admission (POA) indicators.
4. Validate Medicare Severity Diagnosis-Related Group (MS-DRG) assignments, including the identification of Complications or Comorbidities (CCs) and Major Complications or Comorbidities (MCCs), and flag Hospital-Acquired Conditions (HACs) and relevant patient safety indicators.
5. Evaluate AI-generated clinical notes and summaries against source medical records and established coding standards.
6. Validate and assign appropriate diagnostic and procedural codes using ICD-10-CM and ICD-10-PCS classification systems.
7. Identify and resolve discrepancies in diagnosis and procedure coding to maintain accurate record abstraction and data integrity.
8. Provide clear, detailed written feedback on coding errors, documentation gaps, and complex cases to support continuous improvement in AI model performance.

Preferred Qualifications

1. Active certification in one or more of the following: Certified Inpatient Coder (CIC), Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Outpatient Coder (COC), or another recognized AHIMA or AAPC coding certification.
2. Hands‑on experience with inpatient ICD-10-CM and ICD-10-PCS coding.
3. Access to up‑to‑date official ICD-10-CM/PCS coding references and authoritative Coding Clinic guidance.
4. Current experience in inpatient medical coding, clinical documentation improvement (CDI), or a closely related healthcare documentation role.
5. Availability to contribute at least 10 hours per week.
6. Strong knowledge of inpatient coding guidelines, diagnosis sequencing, POA indicators, and MS-DRG assignment.
7. Excellent analytical skills, attention to detail, and the ability to identify and explain coding discrepancies.
8. Ability to work independently, follow established guidelines, and maintain high standards of accuracy and quality.

Ideal Candidate Profile

The ideal candidate is a certified inpatient coding professional with practical experience in ICD-10-CM/PCS coding, diagnosis sequencing, POA reporting, and MS-DRG validation. They can critically evaluate medical documentation, identify coding inconsistencies, and provide actionable feedback to improve the accuracy and reliability of AI-generated healthcare data.