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What Medical Records Specialists Do About this section

Medical records and health information specialists
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 About this section

Medical records and health information technicians
This is one of the few health-related occupations in which there is no direct hands-on patient care.

Medical records specialists held about 186,400 jobs in 2021. The largest employers of medical records specialists were as follows:

Hospitals; state, local, and private 29%
Offices of physicians 19
Professional, scientific, and technical services 9
Administrative and support services 7
Nursing and residential care facilities 5

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.

How to Become a Medical Records Specialist About this section

Medical records specialists
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.

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.

Pay About this section

Medical Records Specialists

Median annual wages, May 2021

Health technologists and technicians

$46,910

Medical records specialists

$46,660

Total, all occupations

$45,760

 

The median annual wage for medical records specialists was $46,660 in May 2021. 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 $29,430, and the highest 10 percent earned more than $74,200.

In May 2021, the median annual wages for medical records specialists in the top industries in which they worked were as follows:

Professional, scientific, and technical services $47,000
Hospitals; state, local, and private 47,000
Administrative and support services 46,900
Nursing and residential care facilities 37,740
Offices of physicians 37,330

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.

Job Outlook About this section

Medical Records Specialists

Percent change in employment, projected 2021-31

Health technologists and technicians

7%

Medical records specialists

7%

Total, all occupations

5%

 

Employment of medical records specialists is projected to grow 7 percent from 2021 to 2031, about as fast as the average for all occupations.

About 14,900 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. As a result, more medical records specialists will be needed to convert related health information into standardized codes to be used for insurance reimbursement and other purposes.

Additional records, coupled with widespread use of electronic health records (EHRs) by healthcare providers, will support demand for specialists to code and maintain the associated information in all areas of the healthcare industry.

Employment projections data for medical records specialists, 2021-31
Occupational Title SOC Code Employment, 2021 Projected Employment, 2031 Change, 2021-31 Employment by Industry
Percent Numeric

SOURCE: U.S. Bureau of Labor Statistics, Employment Projections program

Medical records specialists

29-2072 186,400 198,700 7 12,300 Get data

Contacts for More Information About this section

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

CareerOneStop

For a career video on medical records and health information technicians, visit

Medical Records Specialists

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Medical Records Specialists

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