Medical Records Specialist: ICD/CPT Coding & Compliance

Indian Health Service; McLaughlin (SD); On-site; USD 42,000 - 64,000; Full time

Job summary

Indian Health Service in McLaughlin, SD seeks a Medical Records Technician to support accurate coding and documentation for patient care. This role emphasizes reviewing records for completeness, ensuring diagnoses reflect care provided, and coding using ICD, CPT, HCPCS, CDT, and DSM.

The position requires knowledge of coding guidelines, privacy regulations, and collaboration with providers to clarify documentation. A CPC certification is preferred; U.S.

Qualifications

• 1 year of specialized experience equivalent to GS-06 level supporting diagnoses, treatments and services.
• Initiated documentation clarification requests to obtain diagnosis specificity and procedure details.
• Guided providers on documentation requirements, coding guidelines, and common deficiencies affecting reimbursement.
• Participated in coding reviews, compliance audits, and improvement activities.

Responsibilities

• Review medical records for completeness, identifiers, signatures, dates and reports.
• Evaluate documentation for accuracy, medical necessity and correct CPT coding.
• Review provider notes to ensure appropriate E/M levels and code assignment.
• Assign ICD, CPT, HCPCS, CDT, and DSM codes based on documented diagnoses and procedures.
• Ensure terminology aligns with current guidelines and coding standards.

Skills

Medical coding

CPC certification

HIPAA compliance

Attention to detail

Documentation guidance

Job description

Indian Health Service in McLaughlin, SD seeks a Medical Records Technician to support accurate coding and documentation for patient care. This role emphasizes reviewing records for completeness, ensuring diagnoses reflect care provided, and coding using ICD, CPT, HCPCS, CDT, and DSM.

The position requires knowledge of coding guidelines, privacy regulations, and collaboration with providers to clarify documentation. A CPC certification is preferred; U.S.