Employer description & source details
Inpatient Medical Record Review: Review admission notes, progress notes, operative reports, consultation records, laboratory and imaging results, and discharge summaries to identify relevant diagnoses and procedures. ICD-10-CM and ICD-10-PCS Coding: Assign accurate diagnosis and procedure codes based on clinical documentation and current official coding guidelines. Diagnosis Identification and Sequencing: Identify principal and secondary diagnoses, apply appropriate sequencing rules, and ensure compliance with inpatient coding requirements. MS-DRG Validation: Review and validate Medicare Severity Diagnosis-Related Group (MS-DRG) assignments, including the identification of Complications or Comorbidities (CCs) and Major Complications or Comorbidities (MCCs). Present on Admission Assessment: Assign and validate Present on Admission (POA) indicators in accordance with applicable guidelines. Coding Compliance: Apply inpatient coding conventions, including the Uniform Hospital Discharge Data Set (UHDDS) definitions, ICD-10-CM/PCS Official Guidelines for Coding and Reporting, and relevant AHA Coding Clinic guidance. Clinical Quality and Safety Review: Identify hospital-acquired conditions (HACs), patient safety indicators, and other coding-relevant clinical details where applicable. AI Data Annotation and Evaluation: Annotate and validate clinical data to support AI training, model evaluation, and the development of more accurate automated coding systems. Complex Case Analysis: Investigate ambiguous documentation, resolve coding challenges, and provide evidence-based recommendations for complex inpatient cases. Quality Assurance and Feedback: Deliver structured feedback on coding accuracy, guideline interpretation, and complex scenarios to improve annotation quality and proje
Extracted skills: machine learning, artificial intelligence