Medical Records Coder

micro1 Inc.; United States; Teletrabalho; USD 34 000 - 55 000; Tempo integral

Resumo da oferta

micro1 Inc. is seeking Medical Records Coders (CCS/CIC/CPC) to contribute to a project training AI systems. This contractor role is remote in the US, offering exposure to real-world medical data and coding standards.

You will annotate records, assign ICD-10-CM/PCS and CPT codes, identify diagnoses, and flag documentation gaps. Strong communication and attention to detail are essential to ensure data quality and AI model learning.

Qualificações

• Active AHIMA CCS, CIC, or CPC credential required.
• Hands-on coding experience with ICD-10-CM/PCS and CPT.
• Experience coding in acute care, outpatient, ED, and physician practices.
• Ability to review diverse clinical docs and address coding challenges.
• Excellent written and verbal communication; detail-oriented.

Responsabilidades

• Annotate and review medical records with accurate code assignment.
• Identify principal and secondary diagnoses and apply modifiers/POA where applicable.
• Follow Official Guidelines and AHA Coding Clinic guidance; flag gaps.
• Collaborate with stakeholders to clarify requirements and ensure data integrity.
• Provide feedback on coding guidelines to support project workflow and AI model training.
• Maintain accuracy and completeness of all coding annotations.

Conhecimentos

ICD-10-CM coding

ICD-10-PCS coding

CPT coding

Clinical documentation review

Strong communication

Descrição da oferta de emprego

Role Title: Medical Records Coders

Role Type: Contractor

Location: US - Remote

micro1 is engaging Medical Records Coders (CCS / CIC / CPC certified) to contribute their expertise to a dynamic project for a valued customer. 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. No prior experience in AI is required, your domain knowledge is what matters.

Scope of Work

1. 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.
2. 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.
3. 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.
4. Collaborate with project stakeholders using both written and verbal communication to clarify requirements, resolve documentation ambiguities, and ensure data integrity.
5. Deliver high-quality feedback on coding guidelines and complex cases to support project workflow improvements and enhance AI model understanding.
6. Ensure accuracy and completeness of all coding-related annotations per current best practices and coding standards.

Preferred Qualifications

1. Active AHIMA Certified Coding Specialist (CCS), AAPC Certified Inpatient Coder (CIC), or AAPC Certified Professional Coder (CPC) credential.
2. Thorough expertise in ICD-10-CM, ICD-10-PCS, and CPT, with hands‑on experience coding from medical records.
3. Experience coding across settings such as acute care, outpatient, emergency department, and physician practice.
4. Proficiency in reviewing and coding various types of clinical documentation and addressing complex coding challenges.
5. Strong written and verbal communication skills, demonstrating meticulous attention to detail and clarity.
6. Access to current ICD-10-CM, ICD-10-PCS, and CPT code sets and Official Coding Guidelines.