Medical Records Coder

Medical record coding for AI

Contribute practical coding knowledge to AI training through detailed annotation and review of clinical records. This contractor role is remote within the United States, and no previous AI experience is required.

Record review responsibilities

• Review encounter and progress notes, operative reports, consultations, laboratory and imaging results, and discharge summaries.
• Assign documented diagnoses and procedures accurately using ICD-10-CM, ICD-10-PCS, Current Procedural Terminology and HCPCS.
• Identify principal and secondary diagnoses, sequence codes correctly and assign appropriate modifiers and Present on Admission indicators.
• Follow coding conventions and practices that are neutral across payers, including official coding and reporting guidance and AHA Coding Clinic advice.
• Identify documentation gaps and opportunities for clarification, then work with stakeholders to resolve ambiguity and maintain data integrity.
• Give feedback on complex cases and coding guidance, keeping annotations accurate and complete under current standards.

Preferred qualifications

An active AHIMA Certified Coding Specialist, AAPC Certified Inpatient Coder or AAPC Certified Professional Coder credential is preferred. Detailed knowledge of ICD-10-CM, ICD-10-PCS and Current Procedural Terminology should be supported by experience coding directly from clinical documentation.

Experience across acute care, outpatient care, emergency departments and physician practices is useful. The role benefits from confidence reviewing varied clinical records and resolving complex coding questions.

References and communication

Access to current diagnostic and procedural code sets and official guidelines is preferred. Strong written and spoken communication, precise explanations and careful attention to detail support both collaboration and dependable annotations.