Medical Records & Coding Specialist (CPC Preferred)

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

Job summary

Indian Health Service in Montana seeks a Medical Records Technician to review and code patient records, ensuring completeness and accurate healthcare reporting. You will verify identifiers, dates, and service details while aligning documentation with coding standards (ICD, CPT, HCPCS, DSM).

The role emphasizes collaboration with clinicians to clarify records and improve accuracy, with CPC preferred and federal employment safeguards in place.

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.
• Certified Professional Coder (CPC) preferred.

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 in Montana seeks a Medical Records Technician to review and code patient records, ensuring completeness and accurate healthcare reporting. You will verify identifiers, dates, and service details while aligning documentation with coding standards (ICD, CPT, HCPCS, DSM).

The role emphasizes collaboration with clinicians to clarify records and improve accuracy, with CPC preferred and federal employment safeguards in place.