Medical Records & Coding Specialist (CPC Preferred)

Indian Health Service; Tsaile (AZ); On-site; USD 52,000 - 70,000; Full time

Job summary

Indian Health Service is seeking a Medical Records Technician to support accurate coding and proper documentation across patient records. You will verify diagnoses, treatments, and procedures, ensuring compliance with coding standards and privacy regulations.

In this role you will review records for completeness, assign ICD/CPT/HCPCS codes, and collaborate with clinicians to improve documentation quality and reimbursement outcomes within a federal healthcare setting.

Qualifications

• 1 year of specialized experience at GS-06 level: documenting diagnoses, procedures, and services per coding standards.
• Initiated and monitored documentation clarification requests for diagnosis specificity and procedure details.
• Guided providers and staff on documentation requirements, coding guidelines, and common deficiencies.
• Participated in coding reviews, audits, and performance-improvement activities to assess quality and reimbursement.
• Analyzed coding trends and denial patterns to suggest process improvements.

Responsibilities

• Reviews medical records for completeness, including identifiers, signatures, dates, and reports.
• Evaluates documentation for accuracy, consistency, medical necessity, and appropriate modifier usage; verifies final diagnoses reflect care provided.
• Reviews provider documentation to ensure appropriate 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 coding guidelines.

Skills

Medical coding

Documentation improvement

Compliance & privacy

Audits & improvement

Clinician communication

Job description

Indian Health Service is seeking a Medical Records Technician to support accurate coding and proper documentation across patient records. You will verify diagnoses, treatments, and procedures, ensuring compliance with coding standards and privacy regulations.

In this role you will review records for completeness, assign ICD/CPT/HCPCS codes, and collaborate with clinicians to improve documentation quality and reimbursement outcomes within a federal healthcare setting.