Medical Records Coder & Compliance Specialist

Indian Health Service; San Felipe Pueblo / Katishtya (NM); On-site; USD 50,000 - 70,000; Full time

Job summary

Indian Health Service seeks a Medical Records Technician to review and code medical records, ensuring completeness and fidelity to coding standards. The role requires documenting accuracy, proper CPT/ICD coding, and adherence to privacy policies within Native healthcare settings.

The position involves collaboration with clinical staff to obtain precise information, perform documentation checks, and support quality measures and compliance initiatives.

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.

Job description

Indian Health Service seeks a Medical Records Technician to review and code medical records, ensuring completeness and fidelity to coding standards. The role requires documenting accuracy, proper CPT/ICD coding, and adherence to privacy policies within Native healthcare settings.

The position involves collaboration with clinical staff to obtain precise information, perform documentation checks, and support quality measures and compliance initiatives.