Medical Records Coder (CPC Preferred) – Impact & Compliance

Indian Health Service; Albuquerque (NM); On-site; USD 42,000 - 54,000; Full time

Job summary

Indian Health Service is seeking a Medical Records Technician to ensure accurate coding and documentation in patient records within a federal healthcare environment. The role focuses on reviewing records for completeness, accuracy, and appropriate coding across ICD, CPT, and related systems.

Responsibilities include verifying E/M levels, correct CPT coding, and adherence to coding guidelines, with CPC preferred to enhance accuracy and compliance.

Qualifications

• Specialized experience with diagnosis, procedures, and coding in medical records.
• Guidance on documentation requirements and coding guidelines.
• CPC knowledge or certification preferred.
• Experience with coding reviews, audits, and improvement initiatives.
• Ability to analyze trends in documentation and reimbursement.

Responsibilities

• Reviews medical records for completeness, including identifiers, signatures, dates, and service reports.
• Evaluates documentation for accuracy, medical necessity, and correct modifier usage; verifies diagnoses match care.
• Reviews provider documentation to ensure correct E/M levels and CPT code assignment.
• Assigns and sequences ICD, CPT, HCPCS, CDT, and DSM codes.
• Ensures terminology aligns with current coding nomenclature and guidelines.

Skills

Documentation review

Coding guidance

CPC knowledge

Regulatory compliance

Auditing

Job description

Indian Health Service is seeking a Medical Records Technician to ensure accurate coding and documentation in patient records within a federal healthcare environment. The role focuses on reviewing records for completeness, accuracy, and appropriate coding across ICD, CPT, and related systems.

Responsibilities include verifying E/M levels, correct CPT coding, and adherence to coding guidelines, with CPC preferred to enhance accuracy and compliance.