Medical Records & Coding Specialist

Indian Health Service; Crow Agency (MT); On-site; USD 42,000 - 65,000; Full time

Benefits offered by this job

Federal benefits

Job summary

Indian Health Service is seeking a qualified Medical Records Technician to review and code patient encounters within federal guidelines. The role ensures complete records, accurate diagnoses, and proper CPT/ICD coding based on documented services.

The position requires at least 1 year of specialized experience at GS-6, knowledge of coding standards, and the ability to support documentation improvement efforts. CPC preferred; federal benefits 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

Documentation accuracy

Coding guidelines

Reimbursement knowledge

Audit participation

Job description

Indian Health Service is seeking a qualified Medical Records Technician to review and code patient encounters within federal guidelines. The role ensures complete records, accurate diagnoses, and proper CPT/ICD coding based on documented services.

The position requires at least 1 year of specialized experience at GS-6, knowledge of coding standards, and the ability to support documentation improvement efforts. CPC preferred; federal benefits apply.