Medical Records Technician Coder III Job at Koniag Government Services in Oklahoma City

Requirements: Based on demonstrated proficiency and successful performance in all areas of responsibility, employees may become eligible for telework. Telework is a temporary privilege and may be modified or rescinded at any time due to operational, client, business, or security requirements. Employees approved for telework must: Maintain a dedicated, secure home office workspace. Maintain a reliable high-speed internet connection. Reside within a reasonable commuting distance of Oklahoma City. Report to the office at least twice every two weeks, and more often as needed for meetings or business requirements. The purpose of this position is to interpret, analyze, and assign diagnostic and procedural codes, abstract clinical information into the computer database, and support determinations regarding appropriate utilization of services and medical necessity for hospital and clinic records, including inpatient, day surgery, observation, emergency room, and ambulatory care encounters. The coding function provides a primary source for healthcare data and information, promotes continuity of medical care, and supports compliance with third-party reimbursement policies, regulations, and accreditation guidelines. Under general supervision, the Medical Records Coder III performs coding and abstracting functions of moderate to advanced complexity and supports documentation accuracy, coding compliance, and efficient health information management operations.

Key Responsibilities: Medical Record Analysis: Reviews written, dictated, and electronic clinical documentation to ensure required components of the ambulatory or inpatient visit record are present. Performs quantitative and qualitative analysis of medical records for consistency, adequacy, and completeness. Reviews records to confirm diagnoses, procedures, and supporting documentation are present and appropriately reflected. Identifies inconsistencies, omissions, or discrepancies in the medical record and escalates questions as appropriate. Assists with provider queries related to clarification, specificity, medical necessity, and documentation completeness. Supports documentation quality improvement efforts through accurate review and consistent application of coding rules and standards. Medical Record Coding Applies knowledge of anatomy and physiology, disease processes, pharmacology, diagnostic and procedural terminology, and coding guidelines to assign accurate diagnosis and procedure codes. Utilizes encoder tools, coding books, approved references, and system resources to assign and sequence ICD-10-CM, ICD-10-PCS, CPT, and HCPCS codes. Reviews records to ensure diagnoses and procedures documented by the provider are valid, complete, and appropriately related. Identifies secondary diagnoses, complications, and co-morbid conditions to support complete and accurate code assignment. Reviews provider documentation to support appropriate Evaluation and Management (E&M) level assignment and correct CPT and HCPCS coding. Participates in coding quality reviews, internal audits, and peer review activities as assigned. Maintains required productivity and accuracy standards. Administrative Support During peak workloads, supports health information management operations to promote efficiency and continuity. Maintains accurate logs of completed work and related productivity records. Assists with weekly error reports and correction of orphaned visits and related database issues. Collaborates with supervisors, coding staff, and related personnel to support efficient workflows. Communicates professionally with business office staff and other stakeholders regarding coding and reimbursement matters, as directed. Assists providers and staff, as appropriate, with record completion and correction of documentation deficiencies.

Required Qualifications: High school diploma or equivalent plus 3 or more years of experience in medical coding, medical records, or health information management; or an associate or bachelor degree in Health Information Management, Medical Coding, or a related field with 1 or more years of relevant coding experience. Completion of an accredited Health Information Management or Medical Coding program. Current coding certification such as CCS, CPC, RHIT, or equivalent preferred. Working knowledge of ICD-10-CM/PCS, CPT, HCPCS, and related coding systems. Understanding of coding guidelines, reimbursement principles, and documentation standards. Proficiency with electronic health record systems and coding and encoder applications. Strong attention to detail, analytical skills, and organizational ability. Preferred Qualifications Or Experience Experience working in Indian Health Service or other federal, tribal, or hospital-based healthcare environments. Familiarity with RPMS/EHR, health information management workflows, and outpatient and inpatient coding operations. Knowledge of Medicare and Medicaid billing and reimbursement principles. Familiarity with HIPAA regulations and healthcare compliance requirements. Ability to develop positive working relationships with providers, business office staff, and fellow coding professionals. Possess sufficient initiative, interpersonal relationship skills, and social sensitivity such that he or she can relate constructively to Native American communities. Security And Compliance Requirements You must be able to obtain and maintain a favorable Tier II background investigation determination, as required by the Indian Health Service (IHS), as a condition of access to IHS facilities, systems, and data. Employment is contingent upon successful completion of all credentialing, fingerprinting, identity proofing, and security processing required by IHS and any other authorized government offices. You must also be able to comply with all applicable medical privacy, records confidentiality, and IT security requirements governing access to patient information and federal systems. In this role, you must adhere to HIPAA, HITECH, the Privacy Act, and all IHS privacy and security policies and procedures. This includes protecting electronic and paper records, using only authorized systems and approved access methods, maintaining workstation and password security, completing required privacy and IT security training, and immediately reporting any suspected privacy breach, security incident, or unauthorized disclosure. Compliance Requirements 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. Telework Security Requirements 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. Telework may be suspended or revoked at any time if privacy, security, operational, or contractual concerns arise. Candidate Documentation And Pre-Employment Submission Requirements 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. Our Equal Employment Opportunity PolicyThe company is an equal opportunity employer. The company shall not discriminate against any employee or applicant because of race, color, religion, creed, ethnicity, sex, sexual orientation, gender or gender identity (except where gender is a bona fide occupational qualification), national origin or ancestry, age, disability, citizenship, military/veteran status, marital status, genetic information or any other characteristic protected by applicable federal, state, or local law. We are committed to equal employment opportunity in all decisions related to employment, promotion, wages, benefits, and all other privileges, terms, and conditions of employment. The company is dedicated to seeking all qualified applicants. If you require an accommodation to navigate or apply for a position on our website, please get in touch with Heaven Wood via e-mail at accommodations@koniag-gs.com or by calling 703-488-9377 to request accommodations. Koniag Government Services (KGS) is an Alaska Native Owned corporation supporting the values and traditions of our native communities through an agile employee and corporate culture that delivers Enterprise Solutions, Professional Services and Operational Management to Federal Government Agencies. As a wholly owned subsidiary of Koniag, we apply our proven commercial solutions to a deep knowledge of Defense and Civilian missions to provide forward leaning technical, professional, and operational solutions. KGS enables successful mission outcomes for our customers through solution-oriented business partnerships and a commitment to exceptional service delivery. We ensure long-term success with a continuous improvement approach while balancing the collective interests of our customers, employees, and native communities. For more information, please visit www.koniag-gs.com.