Medical Records Coder

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.

Originally posted on Himalayas