[Hiring] Medical Records Coder @YO AI Labs

Role Description

We are seeking experienced and certified Medical Records Coders to contribute their expertise to an AI training and evaluation project. In this role, you will use your medical coding knowledge to review, annotate, and validate clinical documentation, helping improve how next-generation AI systems interpret medical records and apply accurate coding standards. Your real-world coding experience will support the development of reliable AI models. No prior AI experience is required; your professional expertise is what matters.

Scope of Work

• Review and annotate medical records, including encounter notes, progress notes, operative reports, consultation reports, laboratory and imaging results, and discharge summaries, ensuring accurate ICD-10-CM, ICD-10-PCS, CPT, and HCPCS code assignments based on clinical documentation.
• Identify principal and secondary diagnoses, sequence codes according to applicable guidelines, and assign modifiers and Present on Admission (POA) indicators where required.
• Apply established coding conventions and payer-neutral best practices, including the Official Guidelines for Coding and Reporting and AHA Coding Clinic guidance.
• Identify documentation gaps, inconsistencies, and opportunities for provider queries to support accurate and complete coding.
• Collaborate with project stakeholders through written and verbal communication to clarify requirements, resolve documentation ambiguities, and maintain data integrity.
• Provide expert feedback on coding guidelines and complex cases to improve project workflows and enhance AI model understanding.
• Ensure the accuracy, consistency, and completeness of all coding annotations in accordance with current industry standards and best practices.

Qualifications

• Hold an active AHIMA Certified Coding Specialist (CCS), AAPC Certified Inpatient Coder (CIC), or AAPC Certified Professional Coder (CPC) credential.
• Strong knowledge of ICD-10-CM, ICD-10-PCS, and CPT coding systems, supported by hands-on experience coding medical records.
• Experience coding across multiple healthcare settings, including acute care, outpatient, emergency departments, and physician practices.
• Proficiency in reviewing and interpreting various types of clinical documentation and resolving complex coding challenges.
• Strong understanding of official coding guidelines, coding conventions, and clinical documentation requirements.
• Excellent written and verbal communication skills, with meticulous attention to detail and accuracy.
• Access to current ICD-10-CM, ICD-10-PCS, and CPT code sets, along with the applicable Official Coding Guidelines.

Preferred Qualifications

• Experience with medical record auditing, coding quality reviews, or clinical documentation improvement.
• Familiarity with identifying documentation deficiencies and recommending appropriate provider queries.
• Experience with AI training, data annotation, content validation, or model evaluation projects.