Medical AI-assisted Coding Expert

Refocus LLC; Virginia; Remote; USD 96,000 - 152,000; Full time

Job summary

Refocus LLC is seeking an experienced Medical AI-assisted Coding Expert to work remotely on a long-term contract. The role focuses on expert medical coding across Surgery, Anesthesia, Orthopedics, and Inpatient settings, applying ICD-10-CM/PCS, CPT, HCPCS, and DRG guidelines.

You will evaluate AI-driven coding recommendations, identify gaps, and provide feedback to improve autonomous coding platforms like Fathom, CodaMetrix, and Nym, collaborating with clinical documentation teams.

Qualifications

• Experience with ICD-10-CM, ICD-10-PCS, CPT, HCPCS, DRG, modifiers, documentation guidelines, and coding compliance.
• Experience with autonomous/AI-assisted medical coding platforms and evaluating AI-generated coding recommendations.

Responsibilities

• Review clinical documentation and determine correct medical codes independently.
• Identify missing information, coding gaps, and inaccurate AI recommendations.
• Test, validate, and provide feedback on autonomous coding solutions.

Skills

Medical coding expertise

Surgery coding

Anesthesia coding

Orthopedics coding

Inpatient coding

Coding compliance

Documentation guidelines

Tools

Fathom

CodaMetrix

Nym

Job description

Job Title: Medical AI-assisted Coding Expert

Location: Remote

Duration: Long term contract

JOB DESCRIPTION:

• Seeking experienced Medical Coding SMEs/Experts with strong hands‑on expertise in Surgery, Anesthesia, Orthopedics, and Inpatient coding across complex clinical scenarios.
• Must have deep knowledge of ICD-10-CM, ICD-10-PCS, CPT, HCPCS, DRG, modifiers, documentation guidelines, and coding compliance.
• Experience with autonomous/AI-assisted medical coding platforms and ability to evaluate coding recommendations generated from clinical charts, physician documentation, procedures, prescriptions, and patient information.
• Ability to review clinical documentation and determine the correct medical codes independently, while identifying missing information, coding gaps, inaccurate AI recommendations, and opportunities for coding improvement.
• Looking for experts who can help test, validate, and provide feedback on autonomous coding solutions, particularly solutions similar to Fathom, CodaMetrix, Nym, and other AI-driven medical coding platforms.