Medical Records Specialists

A subset of this occupation's profile is available. Data collection is currently underway to populate other parts of the profile.

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.

Sample of reported job titles: Coder, Health Information Clerk, Health Information Specialist, Health Information Technician (Health Information Tech), Medical Records Clerk, Medical Records Coordinator, Medical Records Technician (Medical Records Tech), Registered Health Information Technician (RHIT)

Occupation-Specific Information

Tasks Save Table: XLSX CSV

  • 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.
  • Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
  • Identify, compile, abstract, and code patient data, using standard classification systems.
  • Maintain or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.
  • Post medical insurance billings.
  • Process and prepare business or government forms.
  • Process patient admission or discharge documents.
  • Protect the security of medical records to ensure that confidentiality is maintained.
  • Release information to persons or agencies according to regulations.
  • Resolve or clarify codes or diagnoses with conflicting, missing, or unclear information by consulting with doctors or others or by participating in the coding team's regular meetings.
  • Retrieve patient medical records for physicians, technicians, or other medical personnel.
  • Review records for completeness, accuracy, and compliance with regulations.
  • Scan patients' health records into electronic formats.
  • Schedule medical appointments for patients.
  • Transcribe medical reports.

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Technology Skills Save Table: XLSX CSV

  • Accounting software — Billing software; NDCMedisoft; QMSoftware Receivables Management; Siemens Soarian Financials
  • Analytical or scientific software — IBM SPSS Statistics Hot technology ; Minitab; SAS Hot technology ; StataCorp Stata
  • Business intelligence and data analysis software — IBM Cognos Impromptu; MicroStrategy; Qlik Tech QlikView; Tableau Hot technology
  • Calendar and scheduling software — MD Synergy Medical Appointment Scheduling; Scheduling software; Siemens Soarian Scheduling
  • Categorization or classification software — 3M Encoder; American Medical Association CodeManager; Computerized indexing systems; DRG grouping software
  • Data base management system software — Teradata Database Hot technology
  • Data base reporting software — Microsoft SQL Server Reporting Services SSRS Hot technology ; SAP Crystal Reports; SoftMed ChartRelease
  • Data base user interface and query software — Encoded archival system EAD; Microsoft Access Hot technology ; Microsoft SQL Server Hot technology ; Structured query language SQL Hot technology ; 4 more
  • Desktop communications software — Eko
  • Development environment software — Microsoft Visual Basic Hot technology ; Microsoft Visual Basic Scripting Edition VBScript
  • Document management software — Hyland Software OnBase; IDX Systems Patient Chart Tracking; SoftMed ChartLocater; SoftMed ChartReserve; 2 more
  • Electronic mail software — Email software; Microsoft Exchange; Microsoft Outlook In-Demand Hot technology
  • Enterprise application integration software — IBM InfoSphere DataStage
  • Enterprise resource planning ERP software — Microsoft Dynamics Hot technology ; SAP Business Objects
  • Expert system software — Information Resource Products Clinical Coding Expert
  • Graphics or photo imaging software — Graphics software
  • Information retrieval or search software — Coding database software
  • Internet browser software — Web browser software
  • Medical software — eClinicalWorks EHR software Hot technology ; Epic Systems In-Demand Hot technology ; MEDITECH software; Welford Chart Notes; 36 more
  • Metadata management software — Quest Erwin Data Modeler
  • Network security and virtual private network VPN equipment software — Virtual private networking VPN software
  • Object or component oriented development software — R Hot technology
  • Office suite software — Corel WordPerfect Office Suite; Microsoft Office software In-Demand Hot technology
  • Operating system software — Microsoft Windows Hot technology
  • Optical character reader OCR or scanning software — Scantron imaging software
  • Presentation software — Microsoft PowerPoint In-Demand Hot technology
  • Process mapping and design software — Microsoft Visio Hot technology
  • Project management software — Microsoft Project Hot technology ; Microsoft SharePoint Hot technology
  • Spreadsheet software — IBM Lotus 1-2-3; Microsoft Excel In-Demand Hot technology
  • Transaction security and virus protection software — Encoder software
  • Voice recognition software — Cyber Records MediChart Express; ScanSoft Naturally Speaking; Speech recognition software; Voice dictation software
  • Word processing software — Microsoft Word Hot technology
Hot technology
Hot Technologies are requirements most frequently included across all employer job postings.
In demand
In Demand skills are frequently included in employer job postings for this occupation.

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Tools Used Save Table: XLSX CSV

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Occupational Requirements

Detailed Work Activities Save Table: XLSX CSV

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Experience Requirements

Job Zone Save Table: XLSX CSV

Title
Job Zone Three: Medium Preparation Needed
Education
Most occupations in this zone require training in vocational schools, related on-the-job experience, or an associate's degree.
Related Experience
Previous work-related skill, knowledge, or experience is required for these occupations. For example, an electrician must have completed three or four years of apprenticeship or several years of vocational training, and often must have passed a licensing exam, in order to perform the job.
Job Training
Employees in these occupations usually need one or two years of training involving both on-the-job experience and informal training with experienced workers. A recognized apprenticeship program may be associated with these occupations.
Job Zone Examples
These occupations usually involve using communication and organizational skills to coordinate, supervise, manage, or train others to accomplish goals. Examples include hydroelectric production managers, desktop publishers, electricians, agricultural technicians, barbers, court reporters and simultaneous captioners, and medical assistants.
SVP Range
(6.0 to < 7.0)

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Training & Credentials

State training
Local training
Certifications

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Apprenticeship Opportunities

Example apprenticeship titles for this occupation:

  • Health Information Management Hospital Coder
  • Medical Coder (Alternate Title: Patient Administration Specialist)
  • Professional Fee Coder

Specific title(s) listed above are vetted by industry and approved by the U.S. Department of Labor for use in a Registered Apprenticeship Program.

Start your career and build your skillset. Visit Apprenticeship.gov external site to learn about opportunities related to this occupation.

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Worker Characteristics

Interests Save Table: XLSX CSV

Occupational InterestInterest
100
 
Conventional — Work involves following procedures and regulations to organize information or data, typically in a business setting. Conventional occupations are often associated with office work, accounting, mathematics/statistics, information technology, finance, or human resources.
56
 
Investigative — Work involves studying and researching non-living objects, living organisms, disease or other forms of impairment, or human behavior. Investigative occupations are often associated with physical, life, medical, or social sciences, and can be found in the fields of humanities, mathematics/statistics, information technology, or health care service.
40
 
Social — Work involves helping, teaching, advising, assisting, or providing service to others. Social occupations are often associated with social, health care, personal service, teaching/education, or religious activities.
31
 
Realistic — Work involves designing, building, or repairing of equipment, materials, or structures, engaging in physical activity, or working outdoors. Realistic occupations are often associated with engineering, mechanics and electronics, construction, woodworking, transportation, machine operation, agriculture, animal services, physical or manual labor, athletics, or protective services.
15
 
Enterprising — Work involves managing, negotiating, marketing, or selling, typically in a business setting, or leading or advising people in political and legal situations. Enterprising occupations are often associated with business initiatives, sales, marketing/advertising, finance, management/administration, professional advising, public speaking, politics, or law.
0
 
Artistic — Work involves creating original visual artwork, performances, written works, food, or music for a variety of media, or applying artistic principles to the design of various objects and materials. Artistic occupations are often associated with visual arts, applied arts and design, performing arts, music, creative writing, media, or culinary art.

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Workforce Characteristics

Wages & Employment Trends

Median wages (2022)
$22.69 hourly, $47,180 annual
State wages
Local wages
Employment (2022)
194,300 employees
Projected growth (2022-2032)
Much faster than average (9% or higher)
Projected job openings (2022-2032)
15,000
State trends
Top industries (2022)
Health Care and Social Assistance (61% employed in this sector)

Source: Bureau of Labor Statistics 2022 wage data external site and 2022-2032 employment projections external site. “Projected growth” represents the estimated change in total employment over the projections period (2022-2032). “Projected job openings” represent openings due to growth and replacement.

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Job Openings on the Web

State job openings
Local job openings

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More Information

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Sources of Additional Information

Disclaimer: Sources are listed to provide additional information on related jobs, specialties, and/or industries. Links to non-DOL Internet sites are provided for your convenience and do not constitute an endorsement.

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