Medical Records Technician Coder IV-Lead

Koniag Government Services, LLC•Oklahoma City, OK

1d•Hybrid

About The Position

Koniag Advisory Business Solutions (KABS) is seeking highly skilled, self-directed Medical Records Coder IV (Lead) professionals to support a large-scale healthcare mission serving hospitals and clinics. This is an opportunity to bring your expertise to a team responsible for coding and billing more than 300,000 patient visits, where accuracy, compliance, sound judgment, and accountability are essential. In this role, you will help ensure the integrity of clinical documentation, support compliant reimbursement, and contribute to the continuity of patient care by accurately interpreting records, assigning diagnostic and procedural codes, and abstracting key clinical data. We are looking for seasoned professionals with a critical eye for detail, deep knowledge of coding conventions and reimbursement requirements, and the confidence to work independently while collaborating effectively with providers, business office staff, and health information management leadership. This position is especially well suited for seasoned professionals who take pride in converting voluminous, complex medical records into billable events, maintaining high ethical standards, identifying discrepancies, and helping healthcare teams improve documentation quality and coding accuracy.

Requirements

High school diploma or equivalent plus 5 or more years of previous experience in medical coding or health information management; or a bachelor degree in Health Information Management and 2 or more years of progressively complex medical coding experience.
Completion of an accredited Health Information Management or Medical Coding program.
Current certification in medical coding such as CCS, CPC, RHIT, or equivalent required.
Advanced knowledge of ICD-10-CM/PCS, CPT, HCPCS, and coding conventions.
Strong understanding of AHIMA and AMA coding guidelines.
Proficiency in electronic health record systems, encoder tools, and health information management workflows.
Strong attention to detail, analytical capability, and sound independent judgment.
Must be able to obtain and maintain a favorable Tier II background investigation determination, as required by IHS.
Must successfully complete all required fingerprinting, identity proofing, credentialing, badge, and access steps.
Must complete required privacy, HIPAA, and IT security training within required timeframes and maintain current status thereafter.
Must comply with all IHS, HHS, facility, and company privacy, confidentiality, records management, and cybersecurity requirements.
Must protect PHI and other sensitive information in both paper and electronic form using required administrative, technical, and physical safeguards.
Must immediately report suspected privacy breaches, improper disclosures, security incidents, malware events, lost devices, or unauthorized access.
Must use only authorized systems, accounts, devices, software, and remote-access methods.
Must maintain workstation, password, and badge security at all times.
Must be able to support periodic access reviews, audits, and compliance checks.
If telework is approved, the employee must maintain a dedicated, private workspace suitable for handling confidential information and must use only authorized equipment, approved connections, and secure access methods.
Final candidates will be required to provide documentation and information necessary to support background investigation, credentialing, and access processing, which may include: Government-issued identity documents for identity proofing. Information needed for fingerprinting and background investigation processing. Current address and prior residence history, as requested. Employment history and related verification information, as requested. Professional certification and training documentation, as required. Any other forms or supporting materials required by IHS, HHS, or authorized security officials.

Nice To Haves

Experience working in Indian Health Service.
Ability to mentor new staff and build cohesive working relationships with team members.
Possess sufficient initiative, interpersonal relationship skills, and social sensitivity such that he or she can relate constructively to Native American communities.
Expertise in Medicare and Medicaid rules, policies, best practices for hospitals and outpatient clinic billing and coding, and reimbursement requirements.
Familiarity with HIPAA regulations and healthcare compliance.

Responsibilities

Performs comprehensive quantitative analysis by reviewing written, dictated, and electronic clinical documentation records to ensure the presence of all required components of the ambulatory or inpatient visit record.
Performs comprehensive qualitative analysis by evaluating the record for documentation consistency and adequacy and ensuring the final diagnosis accurately reflects the care and treatment rendered.
Reviews records for compliance with established third-party reimbursement agencies, special screening criteria, facility policy, medico-legal requirements, and regulatory requirements.
Identifies inconsistencies, discrepancies, and trends within the medical record and formulates provider queries, both written and verbal, for clarification and specificity.
Recommends appropriate modifications to support medical necessity, coding compliance, and adherence to the Correct Coding Initiative, facility policy, and regulatory requirements.
Provides ongoing education and updates to medical staff and other healthcare providers on coding conventions, rules, regulations, and guideline changes.
Applies advanced knowledge of anatomy and physiology, clinical disease processes, pharmacology, diagnostic and procedural terminology, and coding guidelines to assign codes accurately to diagnoses and procedures.
Utilizes encoder tools, coding books, internet resources, and approved references to assign and sequence ICD-10-CM, ICD-10-PCS, CPT, and HCPCS codes based on medical record analysis.
Assures that final diagnoses and procedures documented by the provider are valid and complete.
Analyzes and abstracts information from the medical record to identify secondary complications and co-morbid conditions.
Reviews provider documentation to ensure appropriate Evaluation and Management levels are assigned along with correct CPT and or HCPCS codes.
Performs audits for or in conjunction with the facility compliance plan, performance improvement studies, medical records review processes, and utilization review processes.
Provides reports of findings, education, and feedback to relevant parties and may participate in committees, work groups, teams, and discussions with medical, nursing, and other staff regarding coding, reimbursement, and documentation issues.
Assists in development and modification of facility coding policies and procedures.
Communicates with administrative staff, supervisors, the Administrator, Site Manager, and other hospital staff to resolve coding, abstracting, RPMS, and EHR issues and recommend alternate procedures.
Maintains statistics for documentation deficiencies and assists providers in the completion of incomplete and delinquent records.
Makes final determinations that the medico-legal requirements of the record are complete, accurate, and reflect sufficient data to justify the diagnosis and warranted treatment.
During peak workloads, supports health information management operations to promote efficient operation.
Answers incoming telephone calls and verifies patient eligibility, as needed.
Maintains accurate logs of work completed and related productivity records.
Collaborates with supervisors and related staff to support efficient operations.
Runs weekly error reports to ensure data transmission to the data center.
Corrects error reports through validation of orphaned visits and related database issues.
Performs audits that may include findings from provider documentation trends, coding peer reviews, and reimbursement denials.
Provides reports of findings and feedback to parties involved.
Works with healthcare providers to maintain Superbill and Pick Lists within RPMS/EHR.
Maintains open lines of communication with Business Office staff on reimbursement issues and validity of Table Maintenance within RPMS.