Medical Records Technician Coder IV-Lead

Medical Records Technician Coder IV-Lead

Koniag Advisory Business Solutions, LLC, a Koniag Government Services company, is seeking a Medical Records Technician Coder IV-Lead to support KABS and our government customer in Oklahoma, OKC. This position requires the candidate to be able to obtain a Public Trust.

This position is covered under the Service Contract Act. We offer competitive compensation and an extraordinary benefits package including health, dental and vision insurance, 401K with company matching, paid holidays, paid vacation, paid sick leave and more.

Join Our Team Where Precision, Integrity, and Expertise Matter. 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.

Work Schedule and Hybrid Conditions:

This is a hybrid position based in Oklahoma City, Oklahoma. We anticipate July 1 as the project kick-off date. During the first few weeks of onboarding and initial training, employees are required to work on site full-time, Monday through Friday, 8:00 a.m. to 5:00 p.m. CT, at: 701 Market Dr Oklahoma City, OK 73114.

Core working hours are generally 9:00 a.m. CT to 3:00 p.m. CT, with exact start and end times determined by the Program Manager. Work hours may flex based on client needs.

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 make determinations regarding appropriate utilization of services and medical necessity for all types of hospital and clinic records, including inpatient, day surgery, observation, emergency room, and ambulatory care. The coding function provides the primary source for data and information used in healthcare, promotes continuity of medical care, and ensures compliance with third-party reimbursement policies, regulations, and accreditation guidelines. The Medical Records Coder IV (Lead) serves as a senior technical coding resource and lead-level individual contributor, handling highly complex cases, supporting audits and provider education, mentoring junior coders, and helping strengthen documentation and coding quality across the team.

Key Responsibilities:

Medical Record Analysis

• 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.

Medical Record Coding:

• 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.

Administrative Support:

• 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.

Required Qualifications:

• 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.

Preferred Qualifications or Experience

• 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.

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