Inpatient Medical Coding & AI Data Quality Specialist (CCS/CIC)

About the Role

We are seeking an experienced Inpatient Medical Coding Specialist with an active CCS or CIC credential to contribute to a project focused on improving the accuracy and clinical understanding of advanced AI systems. You will review and annotate inpatient medical records, assign and validate ICD-10-CM and ICD-10-PCS codes, determine principal and secondary diagnoses, and verify MS-DRG assignments. You will apply official inpatient coding guidelines, identify documentation gaps, and provide expert feedback on complex coding cases.

The ideal candidate has hands-on inpatient coding experience, strong knowledge of UHDDS, POA indicators, CC/MCC classification, and current coding standards, and exceptional attention to detail. Prior AI experience is not required.

SENIORITY: Experienced / Specialist

LANGUAGE: Strong written and verbal English

LOCATION: Remote — United States

Key Responsibilities

Annotate and review inpatient medical records, including admission notes, progress notes, operative reports, consultations, laboratory and imaging results, and discharge summaries.

• Assign accurate ICD-10-CM and ICD-10-PCS codes based on clinical documentation and applicable coding guidelines.
• Identify principal and secondary diagnoses and sequence codes according to official inpatient coding conventions.
• Assign Present on Admission (POA) indicators and validate MS-DRG assignments, including the identification of Complications or Comorbidities (CCs) and Major Complications or Comorbidities (MCCs).
• Apply UHDDS definitions, ICD-10-CM/PCS Official Guidelines for Coding and Reporting, and relevant AHA Coding Clinic guidance.
• Identify hospital-acquired conditions (HACs), patient safety indicators, and documentation inconsistencies where applicable.
• Collaborate with project stakeholders to clarify coding requirements, resolve documentation ambiguities, and maintain data integrity.
• Provide structured feedback on coding guidelines, complex cases, and recurring errors to support workflow improvements and AI model training.
• Ensure all coding annotations are accurate, complete, consistent, and aligned with current coding standards.

Requirements

• Active AHIMA Certified Coding Specialist (CCS) or AAPC Certified Inpatient Coder (CIC) credential.
• Hands-on experience with inpatient medical coding.
• Strong knowledge of ICD-10-CM, ICD-10-PCS, and MS-DRG methodology.
• Understanding of principal diagnosis selection, secondary diagnosis reporting, code sequencing, POA indicators, CC/MCC classification, and applicable inpatient coding guidelines.
• Experience reviewing clinical documentation and resolving complex coding challenges.
• Strong written and verbal communication skills.
• Excellent attention to detail and the ability to apply coding rules consistently.
• Access to current ICD-10-CM/PCS code sets, official coding guidelines, and appropriate MS-DRG grouper tools.