Impactful Medical Records Coding Specialist

Indian Health Service; Manderson (SD); On-site; USD 42,000 - 62,000; Full time

Job summary

Indian Health Service is seeking a Medical Records Technician to support coding and documentation accuracy for patient records. The role involves reviewing records, ensuring proper CPT/ICD coding, and maintaining alignment with E/M levels and coding guidelines.

Required experience includes analyzing documentation for accuracy, compliance with privacy rules, and providing guidance on coding standards. A CPC credential is preferred, and federal employment requirements apply.

Qualifications

• 1 year of specialized experience equivalent to GS-06 grade level: Verified documentation supporting diagnoses, treatments, procedures, and services rendered while maintaining compliance with coding standards, privacy regulations, and organizational policies.
• Initiated and monitored documentation clarification requests to obtain diagnosis specificity, procedure details, and supporting clinical information necessary for accurate coding and reporting.
• Assisted providers and clinical staff by providing guidance on documentation requirements, coding guidelines, and common deficiencies affecting reimbursement and quality measures.
• Participated in coding reviews, compliance audits, and performance improvement activities to evaluate documentation quality, coding accuracy, and reimbursement outcomes.
• Assisted with analysis of coding trends, denial patterns, and documentation issues and recommended process improvements to improve efficiency and coding accuracy.

Responsibilities

• Reviews medical records for completeness, including required identifiers, signatures, dates, and reports associated with services rendered.
• Evaluates documentation for accuracy, consistency, medical necessity, and appropriate modifier usage; verifies that final diagnoses accurately reflect care provided.
• Reviews provider documentation to ensure appropriate Evaluation and Management (E/M) levels and correct CPT code assignment.
• Assigns and sequences ICD, CPT, HCPCS, CDT, and DSM codes based on documented diagnoses and procedures.
• Ensures diagnostic and procedural terminology aligns with current medical nomenclature and official coding guidelines.

Skills

Medical coding

Documentation review

E/M level review

CPT/ICD coding

Education

Certified Professional Coder (CPC) preferred

Job description

Indian Health Service is seeking a Medical Records Technician to support coding and documentation accuracy for patient records. The role involves reviewing records, ensuring proper CPT/ICD coding, and maintaining alignment with E/M levels and coding guidelines.

Required experience includes analyzing documentation for accuracy, compliance with privacy rules, and providing guidance on coding standards. A CPC credential is preferred, and federal employment requirements apply.