Medical Records Coder & Compliance Specialist

Indian Health Service; Indian Neck (VA); On-site; USD 42,000 - 52,000; Full time

Job summary

Indian Health Service is seeking a Medical Records Technician to review and code medical records, ensuring completeness and accuracy of diagnoses, procedures, and billing information. The role requires guidance on documentation standards and compliance with coding guidelines.

Candidates with certification as a Certified Professional Coder (CPC) are preferred and a minimum of one year at the GS-06 level is expected.

Qualifications

• One year of specialized experience equivalent to GS-06 level in documenting and coding medical records.
• Initiated and monitored documentation clarification requests for diagnosis specificity and coding details.
• Guided clinicians on documentation requirements, coding guidelines, and common deficiencies affecting reimbursement.

Responsibilities

• Reviews medical records for completeness, including identifiers, signatures, dates, and service-related reports.
• Evaluates documentation for accuracy, consistency, medical necessity, and appropriate modifier usage; verifies final diagnoses 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 terminology aligns with current coding guidelines.

Skills

Attention to detail

Medical coding knowledge

Communication

Job description

Indian Health Service is seeking a Medical Records Technician to review and code medical records, ensuring completeness and accuracy of diagnoses, procedures, and billing information. The role requires guidance on documentation standards and compliance with coding guidelines.

Candidates with certification as a Certified Professional Coder (CPC) are preferred and a minimum of one year at the GS-06 level is expected.