Medical Records Specialists

What the job really is

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.

At a glance

• Sector: Healthcare Practitioners
• O*NET-SOC code: 29-2072
• O*NET job zone: 3 — medium preparation
• Work sample tasks on file: 12
• Tools and technologies listed: 12

What you actually do

Work sample tasks recorded for this occupation:

• 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.

Tools and technology

Epic Systems, Henry Schein Dentrix, IBM SPSS Statistics, MEDITECH software, Microsoft Access, Microsoft Excel, Microsoft Office software, Microsoft Outlook, Microsoft PowerPoint, Microsoft Project, Microsoft SQL Server, Microsoft SQL Server Reporting Services SSRS

What employers expect you to already be comfortable with.

Where this job leads

Related occupations — the usual moves up and sideways:

• Medical Transcriptionists
• Health Information Technologists and Medical Registrars
• Medical Secretaries and Administrative Assistants
• Medical Assistants
• File Clerks
• Patient Representatives
• Document Management Specialists
• Health Informatics Specialists

Getting in

O*NET assigns this occupation job zone 3 (medium preparation). The related occupations above are the realistic routes in and out.

Find openings

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Check this against the source

O*NET OnLine: Medical Records Specialists — the authoritative public-domain profile this page is derived from, including the full task list, reported skills and the wage estimates for your region.

Derived and rewritten from the public-domain O*NET database (U.S. Department of Labor / Employment and Training Administration). Figures are observations, not promises — always confirm salary, licensing and visa requirements with the employer and the relevant authority.