Medical Records & Coding Specialist (CPC Preferred)

Indian Health Service; Zia Pueblo (NM); On-site; USD 45,000 - 65,000; Full time

Job summary

Indian Health Service is seeking a Medical Records Technician to review and code medical records, ensuring complete documentation, accuracy, and proper coding for diagnoses and procedures. The role requires attention to detail and adherence to coding guidelines and privacy regulations.

Preferred qualifications include CPC certification. Candidates will participate in audits and process improvements to enhance reimbursement and data quality in a federally supported healthcare setting.

Qualifications

• 1 year of specialized experience equivalent to GS-06: verified documentation supporting diagnoses, treatments, procedures, and services rendered while complying with coding standards and privacy rules.
• Initiated requests to obtain diagnosis specificity and procedure details for accurate coding and reporting.
• Assisted providers with 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 and coding accuracy.

Responsibilities

• Review medical records for completeness (identifiers, signatures, dates, reports).
• Evaluate documentation for accuracy and medical necessity; verify diagnoses reflect care provided.
• Review provider notes to ensure correct E/M levels and CPT codes.
• Assign and sequence ICD, CPT, HCPCS, CDT, and DSM codes based on documented info.
• Ensure terminology aligns with current coding guidelines.

Skills

Medical coding

Documentation accuracy

Regulatory compliance

Provider communications

Tools

Coding systems (ICD/CPT/HCPCS)

Job description

Indian Health Service is seeking a Medical Records Technician to review and code medical records, ensuring complete documentation, accuracy, and proper coding for diagnoses and procedures. The role requires attention to detail and adherence to coding guidelines and privacy regulations.

Preferred qualifications include CPC certification. Candidates will participate in audits and process improvements to enhance reimbursement and data quality in a federally supported healthcare setting.