Education:
Medical Records Specialist
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Job Outlook:
Faster than average
Education:
Postsecondary nondegree award
Salary
High:
$75,460.00
Average:
$51,090.00
Hourly
Average:
$24.56
What they do:
Compile, process, and maintain medical records of hospital and clinic patients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the healthcare system. Classify medical and healthcare concepts, including diagnosis, procedures, medical services, and equipment, into the healthcare industry's numerical coding system. Includes medical coders.
On the job, you would:
- Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.
- Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
- Consult classification manuals to locate information about disease processes.
Important Qualities
Analytical skills. Medical records specialists must interpret medical documentation to assess diagnoses, which they then code into a patient’s medical record.
Detail oriented. Medical records specialists must be precise about verifying and coding patient information.
Integrity. Medical records specialists must exercise discretion and act ethically when working with patient data to protect patient confidentiality, as required by law.
Interpersonal skills. Medical records specialists need to discuss patient information, discrepancies, and data requirements with physicians, finance personnel, and other workers involved in patient care and recordkeeping.
Job Details
Responsibilities
Classify materials according to standard systems.
Record patient medical histories.
Maintain medical or professional knowledge.
Enter patient or treatment data into computers.
Collect medical information from patients, family members, or other medical professionals.
Code data or other information.
Maintain medical facility records.
Process medical billing information.
Prepare official health documents or records.
Process healthcare paperwork.
Process healthcare paperwork.
Maintain security.
Perform clerical work in medical settings.
Communicate with management or other staff to resolve problems.
Perform clerical work in medical settings.
Monitor medical facility activities to ensure adherence to standards or regulations.
Process healthcare paperwork.
Perform clerical work in medical settings.
Schedule appointments.
Schedule patient procedures or appointments.
Perform clerical work in medical settings.
What Medical Records Specialists Do
Medical records specialists validate and enter patients' health information into electronic health records systems.
Medical records specialists compile, process, and maintain patient files. They also may classify and enter patients’ medical information into the healthcare industry's numerical coding system.
Duties
Medical records specialists typically do the following:
- Review patients’ records for timeliness, completeness, and accuracy
- Use classification systems to assign clinical codes for patients’ diagnoses, procedures, medical services, and related information
- Maintain and retrieve records for insurance reimbursement and data analysis
- Electronically record data for collection, storage, analysis, retrieval, and reporting
- Ensure confidentiality of patients’ records
Medical records specialists have a variety of data entry and recordkeeping tasks. They may gather patients’ medical histories, symptoms, test results, treatments, and other health information and enter the details into electronic health records (EHR) systems. Some workers categorize medical information for purposes such as insurance reimbursement and providing data to clinicians.
When handling medical records, these workers follow administrative, ethical, and legal requirements for safeguarding patient privacy. Medical records specialists also may serve as gatekeepers for access to patient files. They ensure access only to authorized people and retrieve, scan, and transmit files according to established protocols.
Medical coders assign the diagnosis and procedure codes for patient care, population health statistics, and billing purposes. For example, they might review patient information for preexisting conditions, such as diabetes, to ensure proper coding of patient data. They also work as the liaison between healthcare providers and billing offices.
Although medical records specialists do not provide direct patient care, they work regularly with registered nurses and other healthcare workers. They meet with these workers to clarify diagnoses or to get additional information.
For information about other workers who deal with healthcare records, see the profile for health information technologists and medical registrars.
Work Environment
Medical records specialists held about 194,300 jobs in 2022. The largest employers of medical records specialists were as follows:
| Hospitals; state, local, and private | 27% |
| Offices of physicians | 19 |
| Professional, scientific, and technical services | 9 |
| Management of companies and enterprises | 9 |
| Administrative and support services | 8 |
Medical records specialists typically work at a computer.
Work Schedules
Most medical records specialists work full time. In healthcare facilities that are always open, such as hospitals, specialists may work shifts, including nights or weekends.
Getting Started
How to Become a Medical Records Specialist
Employers may prefer to hire medical records specialists who have acquired certification.
Medical records specialists typically need a postsecondary certificate to enter the occupation, although some qualify with a high school diploma. Others might need an associate’s degree. Certification may be required or preferred.
Education
A high school diploma or equivalent and experience in a healthcare setting are enough to qualify for some positions, but others may require a postsecondary certificate or an associate’s or bachelor’s degree.
High school students may benefit from taking classes in subjects such as biology, computer science, and anatomy.
Community colleges and technical schools offer certificate and associate’s degree programs for medical records specialists. These programs typically include courses in medical terminology, health data requirements and standards, and classification and coding systems.
Licenses, Certifications, and Registrations
Employers may prefer to hire medical records specialists who have certification, or they may expect applicants to earn certification shortly after being hired. For example, some medical records specialists earn the Registered Health Information Technician (RHIT) credential; certifications for medical coders include the Certified Billing & Coding Specialists (CBCS), Certified Coding Associate (CCA), Certified Coding Specialist (CCS), and Certified Professional Coder (CPC).
Certifications usually require candidates to pass an exam and might require previous experience or education. Certificate, associate’s, or bachelor’s degree programs may help students to meet these requirements.
Advancement
Medical records specialists may advance to become health information technologists or medical registrars or medical or health services managers after completing a higher certification program or earning a degree in health information technology. Requirements vary by facility.
Job Outlook
Employment of medical records specialists is projected to grow 8 percent from 2022 to 2032, faster than the average for all occupations.
About 15,000 openings for medical records specialists are projected each year, on average, over the decade. Many of those openings are expected to result from the need to replace workers who transfer to different occupations or exit the labor force, such as to retire.
Employment
An increasing share of the population is entering older age groups, which typically require more medical services. In addition, there is a growing prevalence of heart disease, diabetes, and other chronic conditions. As a result, more medical records specialists will be needed to translate patient information and services delivered into standardized codes to be used for insurance reimbursement and other purposes.
However, the increase in adoption of Artificial Intelligence (AI)-powered solutions that make the medical coding process more efficient may affect the demand for these workers.
Contacts for More Information
For more information about medical records specialists, including details about certification, visit
American Health Information Management Association
American Academy of Professional Coders
National Healthcareer Association
For a list of accredited training programs at the associate's degree level and above, visit
Commission on Accreditation for Health Informatics and Information Management Education
Similar Occupations
This table shows a list of occupations with job duties that are similar to those of medical records specialists.
| Occupation | Job Duties | Entry-Level Education | Median Annual Pay, May 2022 | |
|---|---|---|---|---|
|
Health Information Technologists and Medical Registrars |
Health information technologists and medical registrars advise organizations on computerized healthcare systems and analyze clinical data. |
Associate's degree | $58,250 |
|
Information Clerks |
Information clerks perform routine clerical duties, maintain records, collect data, and provide information to customers. |
See How to Become One | $38,710 |
|
Medical and Health Services Managers | Medical and health services managers plan, direct, and coordinate the business activities of healthcare providers. | Bachelor's degree | $104,830 |
|
Medical Assistants |
Medical assistants complete administrative and clinical tasks, such as scheduling appointments and taking patients’ vital signs. |
Postsecondary nondegree award | $38,270 |
|
Medical Transcriptionists |
Medical transcriptionists use electronic devices to convert voice recordings from physicians and other healthcare workers into formal reports. |
Postsecondary nondegree award | $34,730 |
|
Pharmacy Technicians |
Pharmacy technicians help pharmacists dispense prescription medication to customers or health professionals. |
High school diploma or equivalent | $37,790 |