Medical Records Technician (Coder)

Indian Health Service; Wagner (SD); On-site; USD 45,000 - 60,000; Full time

Job summary

The Indian Health Service is seeking a qualified candidate for a role focused on ensuring the accuracy and completeness of medical records in Wagner, South Dakota. This position involves reviewing documentation and assigning appropriate medical codes, supporting healthcare operations while ensuring compliance with regulatory standards.

Your role will include evaluating provider documentation, engaging in coding audits, and collaborating with clinical staff to enhance the quality of healthcare delivery. Candidates with coding experience and strong attention to detail are encouraged to apply.

Qualifications

• Experience in reviewing medical records and ensuring compliance with coding standards.
• Ability to verify diagnoses and procedures are accurately recorded.
• Familiarity with ICD, CPT, HCPCS, CDT coding.

Responsibilities

• Review medical records for completeness and accuracy.
• Evaluate documentation for medical necessity and coding accuracy.
• Assign and sequence appropriate codes for diagnoses and procedures.

Skills

Medical coding

Documentation review

Regulatory compliance

Patient care support

Job description

Summary

Join the Indian Health Service and make a meaningful impact in Native communities. In this role, you will support vital healthcare operations that ensure patients receive timely, high-quality care. If you're looking for a rewarding career where your work directly supports patient services and community well-being, we encourage you to apply.

Duties

• 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.

Total Compensation Package

Check out IHS's outstanding total compensation package for this job: Medical Records Technician Total Compensation | Pay (ihs.gov).

Requirements

REAL ID will be required beginning May 7, 2025, in accordance with 6 C.F.R. 37.5 (2021). U.S. Citizenship is required. Selective Service Registration is required for males born after 12/31/1959. The position may be subject to a probationary period.

Background Investigation Requirement

This position requires the successful completion of a federal background investigation as a condition of employment. Applicants must complete required background investigation forms within five (5) calendar days of issuance to avoid processing delays.

Financial Suitability Requirement

Applicants must demonstrate financial responsibility, maintain good standing with creditors, and satisfy all legal financial obligations prior to applying. Individuals with substantial delinquent or unresolved financial obligations may be deemed unsuitable for employment.

Qualifications

To qualify for this position, your resume must state sufficient experience and/or education, to perform the duties of the specific position for which you are applying.

Minimum Qualifications

• Verified documentation supported 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.

Education

There are no education requirements.