Medical Records Specialist - Coding & Compliance (CPC)

Indian Health Service; Suffolk (VA); On-site; USD 52,000 - 66,000; Full time

Job summary

Indian Health Service in the United States is hiring a Medical Records Technician to support coding accuracy and medical documentation. The role involves reviewing records, ensuring proper coding, and maintaining compliance with privacy regulations.

Candidates with CPC certification are preferred, and one year of specialized experience at GS-06 is required. The position emphasizes meticulous documentation and accurate reporting to support quality care in Native communities.

Qualifications

• 1 year of specialized experience equivalent to GS-06 level supporting coding and documentation.
• Initiated and monitored documentation clarification requests for diagnosis specificity and supporting information.
• Assisted providers and clinical staff by giving guidance on documentation requirements, coding guidelines, and common deficiencies.
• Participated in coding reviews, compliance audits, and performance improvement activities.
• Assisted with analysis of coding trends, denial patterns, and documentation issues; recommended process improvements.

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 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

Coding accuracy

Privacy regulations

Quality assurance

Clinical guidance

Job description

Indian Health Service in the United States is hiring a Medical Records Technician to support coding accuracy and medical documentation. The role involves reviewing records, ensuring proper coding, and maintaining compliance with privacy regulations.

Candidates with CPC certification are preferred, and one year of specialized experience at GS-06 is required. The position emphasizes meticulous documentation and accurate reporting to support quality care in Native communities.