What Medical Records and Health Information Specialists Do About this section
Medical records and health information specialists verify and validate patients' health information, including their medical history, symptoms, and examination and test results.
Medical records and health information specialists organize, manage, and code health information data. They use various classification systems to code and categorize patient information for insurance reimbursement purposes, for databases and registries, and to maintain patients’ medical and treatment histories.
Duties
Medical records and health information specialists typically do the following:
Review patients’ records for timeliness, completeness, and accuracy
Organize and update information in clinical databases or registries
Use classification systems to assign clinical codes for insurance reimbursement and data analysis
Electronically record data for collection, storage, analysis, retrieval, and reporting
Maintain confidentiality of patients’ records
Medical records and health information specialists verify and validate patients’ health information, including their medical history, symptoms, examination and test results, treatments, and other information about healthcare services provided to patients. Their duties vary by employer and by the size of the facility in which they work.
Although medical records and health information 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.
Medical records and health information specialists use electronic health records (EHRs) software, following EHR security and privacy practices to analyze electronic data and improve healthcare information.
The following are examples of types of medical records and health information specialists:
Cancer registrars review patients’ records and pathology reports to verify completeness and accuracy. They assign classification codes to represent the diagnosis and treatment of cancers and benign tumors. Cancer registrars conduct annual followups to track treatment, survival, and recovery. They compile and analyze cancer patient information for research purposes, and they maintain facility, regional, and national databases of cancer patients.
Health information technicians collect, analyze, and track treatment and followup information on patients. They respond to record requests and validate authorizations and other legal requests. These technicians also provide administrative support to other staff in the health information management department.
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.
This is one of the few health-related occupations in which there is no direct hands-on patient care.
Health information technologists, medical registrars, surgical assistants, and healthcare practitioners and technical workers, all other held about 81,400 jobs in 2020. The largest employers of health information technologists, medical registrars, surgical assistants, and healthcare practitioners and technical workers, all other were as follows:
General medical and surgical hospitals; state, local, and private
33%
Offices of physicians
10
Educational services; state, local, and private
7
Federal government
6
Professional, scientific, and technical services
5
Medical dosimetrists, medical records specialists, and health technologists and technicians, all other held about 335,000 jobs in 2020. The largest employers of medical dosimetrists, medical records specialists, and health technologists and technicians, all other were as follows:
General medical and surgical hospitals; state, local, and private
33%
Outpatient care centers
16
Offices of physicians
14
Administrative and support services
5
Government
5
Medical records and health information specialists typically work at a computer.
Work Schedules
Most medical records and health information specialists work full time. In healthcare facilities that are always open, such as hospitals, specialists may work evening or overnight shifts.
How to Become a Medical Records or Health Information Specialist About this section
Medical records and health information specialists organize and update information in clinical databases or registries.
Medical records and health information specialists typically need a postsecondary certificate to enter the occupation, although some qualify with a high school diploma. Others need an associate’s or higher degree. Certification is often required.
Education
A high school diploma or equivalent and experience in a healthcare setting are enough to qualify for some positions, but others require postsecondary education.
Postsecondary certificate and degree programs in health information technology typically include courses in medical terminology, health data requirements and standards, and classification and coding systems. Applicants may increase their chances of admission by taking high school courses in health, computer science, math, and biology.
Employers may prefer to hire medical records and health information specialists who have certification, or they may expect applicants to earn certification shortly after being hired. Certifications available for medical records and health information specialists include the Certified Professional Coder (CPC), the Certified Coding Associate (CCA), and the Registered Health Information Technician (RHIT).
Some certifications require candidates to pass an exam. Others require graduation from an accredited program. Many coding certifications also require coding experience in a work setting. Once certified, specialists typically must renew their certification regularly and take continuing education courses.
A few states and facilities require cancer registrars to be certified. Certification as a Certified Tumor Registrar (CTR) requires completion of a formal education program and experience, along with passing an exam.
Advancement
Specialists may advance to become medical or health services managers after completing a higher certification program or earning a bachelor’s or master’s degree in health information technology. Requirements vary by facility.
Important Qualities
Analytical skills. Medical records and health information specialists must interpret medical documentation to assess diagnoses, which they then code into a patient’s medical records.
Detail oriented. Medical records and health information specialists must be precise about verifying and coding patient information.
Integrity. Medical records and health information specialists must exercise discretion and act ethically when working with patient data to protect patient confidentiality, as required by law.
Interpersonal skills. Medical records and health information specialists need to be able to discuss patient information, discrepancies, and data requirements with physicians, finance personnel, and other workers involved in patient care and recordkeeping.
Medical Records and Health Information Specialists
Median annual wages, May 2020
Health information technologists, medical registrars, surgical assistants, and healthcare practitioners and technical workers, all other
$51,840
Health technologists and technicians
$45,620
Medical records and health information specialists
$45,240
Medical dosimetrists, medical records specialists, and health technologists and technicians, all other
$44,090
Total, all occupations
$41,950
Note: All Occupations includes all occupations in the U.S. Economy. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics
The median annual wage for health information technologists, medical registrars, surgical assistants, and healthcare practitioners and technical workers, all other was $51,840 in May 2020.
The median wage is the wage at which half the workers in an occupation earned more than that amount and half earned less. The lowest 10 percent earned less than $29,130, and the highest 10 percent earned more than $105,690.
The median annual wage for medical dosimetrists, medical records specialists, and health technologists and technicians, all other was $44,090 in May 2020.
The lowest 10 percent earned less than $28,800, and the highest 10 percent earned more than $73,370.
In May 2020, the median annual wages for health information technologists, medical registrars, surgical assistants, and healthcare practitioners and technical workers, all other in the top industries in which they worked were as follows:
Federal government
$99,750
Professional, scientific, and technical services
63,970
General medical and surgical hospitals; state, local, and private
52,480
Educational services; state, local, and private
47,860
Offices of physicians
46,590
In May 2020, the median annual wages for medical dosimetrists, medical records specialists, and health technologists and technicians, all other in the top industries in which they worked were as follows:
Government
$54,650
General medical and surgical hospitals; state, local, and private
46,970
Administrative and support services
43,890
Outpatient care centers
40,220
Offices of physicians
39,190
Most medical records and health information specialists work full time. In healthcare facilities that are always open, such as hospitals, specialists may work evening or overnight shifts.
Medical Records and Health Information Specialists
Percent change in employment, projected 2020-30
Health information technologists, medical registrars, surgical assistants, and healthcare practitioners and technical workers, all other
11%
Medical records and health information specialists
9%
Medical dosimetrists, medical records specialists, and health technologists and technicians, all other
9%
Health technologists and technicians
9%
Total, all occupations
8%
Note: All Occupations includes all occupations in the U.S. Economy. Source: U.S. Bureau of Labor Statistics, Employment Projections program
Overall employment
of medical records and health information specialists is projected to grow
9 percent from 2020 to 2030, about as fast as the average for all occupations.
About 34,300 openings for medical records and health information 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 aging population will require more medical services, and medical records and health information specialists will be needed to organize and manage the older generations’ health information data. This will mean more claims for reimbursement from insurance companies.
Additional records, coupled with widespread use of electronic health records (EHRs) by all types of healthcare providers, will lead to an increased need for specialists to organize and manage the associated information in all areas of the healthcare industry.
Medical registrars are expected to continue to be in high demand. With an increase in the older population, there will likely be more types of special purpose registries because many illnesses are detected and treated later in life.
Employment projections data for medical records and health information specialists, 2020-30
Occupational Title
SOC Code
Employment, 2020
Projected Employment, 2030
Change, 2020-30
Employment by Industry
Percent
Numeric
SOURCE: U.S. Bureau of Labor Statistics, Employment Projections program
Medical records and health information specialists
—
416,400
453,600
9
37,100
—
Medical dosimetrists, medical records specialists, and health technologists and technicians, all other