Clinical Documentation Reviewer | $70/hr Remote

Crossing Hurdles; United States; On-site; USD 70,000 - 120,000; Full time

Job summary

Crossing Hurdles is seeking an experienced inpatient coder to ensure accurate ICD-10-CM/PCS coding and DRG determinations. You will review medical records, assess MCC/CC/POA implications, and flag documentation gaps for queries. Proficiency with AHIMA/AAPC guidelines and access to current ICD-10 code sets is required.

This role focuses on data integrity in inpatient settings. Responsibilities include evaluating AI-generated notes for accuracy and aligning inpatient coding with industry standards

Qualifications

• Active coding certification such as CIC, CCS, RHIA, or RHIT, or another AHIMA or AAPC coding credential.
• Inpatient ICD-10-CM and ICD-10-PCS coding experience, including DRG, MCC/CC, and POA concepts.
• Access to current official ICD-10 code sets and guidelines, and familiarity with AHA Coding Clinic.
• Currently working in inpatient coding, clinical documentation improvement, or a closely related role.

Responsibilities

• Review inpatient medical records to ensure accurate ICD-10-CM and ICD-10-PCS coding in line with current guidelines.
• Determine the principal and secondary diagnoses for the full admission and assess how MCCs, CCs, and procedures affect DRG assignment.
• Review clinical documentation for accuracy and completeness, and flag opportunities for provider queries.
• Evaluate AI-generated clinical notes, summaries, and code suggestions against real-world documentation and inpatient coding standards.
• Identify and resolve diagnosis and procedure coding discrepancies to protect data integrity.
• Enter and validate AI-generated patient information in inpatient medical record and encoder systems.

Job description

• Review inpatient medical records to ensure accurate ICD-10-CM and ICD-10-PCS coding in line with current guidelines.
• Determine the principal and secondary diagnoses for the full admission and assess how MCCs, CCs, and procedures affect DRG assignment.
• Review clinical documentation for accuracy and completeness, and flag opportunities for provider queries.
• Evaluate AI-generated clinical notes, summaries, and code suggestions against real-world documentation and inpatient coding standards.
• Identify and resolve diagnosis and procedure coding discrepancies to protect data integrity.
• Enter and validate AI-generated patient information in inpatient medical record and encoder systems.

Requirements

• Active coding certification such as CIC, CCS, RHIA, or RHIT, or another AHIMA or AAPC coding credential.
• Inpatient ICD-10-CM and ICD-10-PCS coding experience, including DRG, MCC/CC, and POA concepts.
• Access to current official ICD-10 code sets and guidelines, and familiarity with AHA Coding Clinic.
• Currently working in inpatient coding, clinical documentation improvement, or a closely related role.