Medical Records Specialists
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.
53 alternate job titles:
Certified Coding Specialist
Certified Medical Coder
Certified Professional Coder (CPC)
Clinical Documentation Specialist
Clinical Office Technician (Clinical Office Tech)
Coder
Coding Specialist
Disability Rater
Electronic Health Records Specialist (EHR Specialist)
Fee Coder
Health Informatics Specialist
Health Information Clerk
Health Information Coder
Health Information Management Hospital Coder (HIM Hospital Coder)
Health Information Management Inpatient Coding Auditor (HIM Inpatient Coding Auditor)
Health Information Management Technician (HIM Tech)
Health Information Specialist
Health Information Systems Technician (Health Information Systems Tech)
Health Information Technician (Health Information Tech)
Health Record Technician (Health Record Tech)
Health Records Technician
Health Services Information Specialist
Inpatient Coder
Insurance Coder
Medical Administrative Specialist
Medical Administrative Technician (Medical Administrative Tech)
Medical Bill Coder
Medical Biller
Medical Biller Coder
Medical Billing Coder
Medical Billing Specialist
Medical Claims Processor
Medical Coder
Medical Coding Specialist
Medical Coding Technician (Medical Coding Tech)
Medical Insurance Coder
Medical Insurance Coding Specialist
Medical Office Technician (Medical Office Tech)
Medical Record Assistant
Medical Record Coder
Medical Record Specialist
Medical Records Clerk
Medical Records Coordinator
Medical Records Custodian
Medical Records Specialist
Medical Records Technician (Medical Records Tech)
Medical Reimbursement Specialist
Medical Scribe
Outpatient Coder
Patient Administration Specialist
Registered Health Information Technician (RHIT)
Release of Information Specialist
ROI Medical Records Specialist (Release of Information Medical Records Specialist)
Salary Information
Medical Records Specialists: $50,250 (median) per year.
Starting salary (10th percentile).
Required expreience: Varies by Company
Data source: U.S. Bureau of Labor Statistics
Daily Tasks & Responsibilities
| Task Description | Category |
|---|---|
| Classify materials according to standard systems. | General |
| Record patient medical histories. | General |
| Enter patient or treatment data into computers. | General |
| Collect medical information from patients, family members, or other medical professionals. | General |
| Code data or other information. | General |
| Process medical billing information. | General |
| Prepare official health documents or records. | General |
| Process healthcare paperwork. | General |
| Perform clerical work in medical settings. | General |
| Schedule appointments. | General |
| Schedule patient procedures or appointments. | General |
| Maintain medical or professional knowledge. | Maintenance |
| Maintain medical facility records. | Maintenance |
| Maintain security. | Maintenance |
| Monitor medical facility activities to ensure adherence to standards or regulations. | Maintenance |
| Communicate with management or other staff to resolve problems. | Management |
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Technology Requirements
| Technology | Description |
|---|---|
| Epic Systems | Medical software |
| Microsoft Excel | Spreadsheet software |
| Microsoft Office software | Office suite software |
| Microsoft Outlook | Electronic mail software |
| Microsoft Word | Word processing software |
| Henry Schein Dentrix | Medical software |
| IBM SPSS Statistics | Analytical or scientific software |
| MEDITECH software | Medical software |
| Microsoft Dynamics | Enterprise resource planning ERP software |
| Microsoft PowerPoint | Presentation software |
| Microsoft Project | Project management software |
| Microsoft SharePoint | Document management software |
| Microsoft Visio | Process mapping and design software |
| Microsoft Visual Basic | Development environment software |
| Microsoft Windows | Operating system software |
| R | Object or component oriented development software |
| SAS | Analytical or scientific software |
| eClinicalWorks EHR software | Medical software |
| 3M Encoder | Categorization or classification software |
| Allscripts EHR | Medical software |
| Amazing Charts | Medical software |
| American Medical Association CodeManager | Categorization or classification software |
| Azalea Health Azalea EHR | Medical software |
| Billing software | Accounting software |
| Coding database software | Information retrieval or search software |
| ComChart EMR | Medical software |
| Computerized indexing systems | Categorization or classification software |
| Corel WordPerfect Office Suite | Office suite software |
| Cyber Records MediChart Express | Voice recognition software |
| DRG grouping software | Categorization or classification software |
| Digital Imaging Communications in Medicine DICOM medical imaging software | Medical software |
| EHS CareRevolution | Medical software |
| Eko | Desktop communications software |
| Electronic medical record EMR software | Medical software |
| Electronic medical record EMR systems | Medical software |
| Email software | Electronic mail software |
| Encoder software | Transaction security and virus protection software |
| Fox Meadows Accent Data Manager | Document management software |
| Fox Meadows EncounterManager | Medical software |
| GE Healthcare Logician | Medical software |
| Graphics software | Graphics or photo imaging software |
| Greenway Medical Technologies PrimeChart | Medical software |
| HMS | Medical software |
| Health Care Data HealthProbe | Medical software |
| Healthcare common procedure coding system HCPCS | Medical software |
| Holt Systems eMedRec | Medical software |
| Hyland Software OnBase | Document management software |
| IBM InfoSphere DataStage | Enterprise application integration software |
| IBM Lotus 1-2-3 | Spreadsheet software |
| IDX Systems IDXtend | Medical software |
| IDX Systems Patient Chart Tracking | Document management software |
| Information Resource Products Clinical Coding Expert | Expert system software |
| Laserfiche software | Document management software |
| LeonardoMD Renaissance | Medical software |
| MD Synergy Medical Appointment Scheduling | Calendar and scheduling software |
| MedStar Systems DrWorks | Medical software |
| Mediasoft mediOFFICE | Medical software |
| MedicWare EMR | Medical software |
| Medical condition coding software | Medical software |
| Medical procedure coding software | Medical software |
| Microsoft Exchange | Electronic mail software |
| Microsoft Visual Basic Scripting Edition VBScript | Development environment software |
| Minitab | Analytical or scientific software |
| NCG Medical Systems d-Chart | Medical software |
| NDCMedisoft | Accounting software |
| NextGen Healthcare Information Systems EMR | Medical software |
| PCC EHR | Medical software |
| PCC Pediatric Partner | Medical software |
| PowerMed | Medical software |
| Practice Partner Patient Records | Medical software |
| Presentation software | Presentation software |
| QMSoftware Receivables Management | Accounting software |
| SAP Business Objects | Enterprise resource planning ERP software |
| SOAPware EMR | Medical software |
| STAT! Systems QD Clinical | Medical software |
| ScanSoft Naturally Speaking | Voice recognition software |
| Scantron imaging software | Optical character reader OCR or scanning software |
| Scheduling software | Calendar and scheduling software |
| Siemens Soarian Financials | Accounting software |
| Siemens Soarian Scheduling | Calendar and scheduling software |
| SoftMed ChartLocater | Document management software |
| SoftMed ChartReserve | Document management software |
| Speech recognition software | Voice recognition software |
| StataCorp Stata | Analytical or scientific software |
| SynaMed EMR | Medical software |
| VantageMed ChartKeeper | Medical software |
| Virtual private networking VPN software | Network security and virtual private network VPN equipment software |
| Visionary Medical Systems Visionary OFFICE PM | Medical software |
| Voice dictation software | Voice recognition software |
| Web browser software | Internet browser software |
| Welford Chart Notes | Medical software |
| Word processing software | Word processing software |
| e-MDs topsChart | Medical software |
| eMDs Practice Partner | Medical software |
| Microsoft Access | Data base user interface and query software |
| Microsoft SQL Server | Data base user interface and query software |
| Microsoft SQL Server Reporting Services SSRS | Data base reporting software |
| Structured query language SQL | Data base user interface and query software |
| Tableau | Business intelligence and data analysis software |
| Teradata Database | Data base management system software |
| Encoded archival system EAD | Data base user interface and query software |
| EndoSoft | Data base user interface and query software |
| Entity Management Software | Data base user interface and query software |
| Fox Meadows ChartingPlus | Data base user interface and query software |
| IBM Cognos Impromptu | Business intelligence and data analysis software |
| MicroStrategy | Business intelligence and data analysis software |
| Purkinje Dossier | Data base user interface and query software |
| Qlik Tech QlikView | Business intelligence and data analysis software |
| Quest Erwin Data Modeler | Metadata management software |
| SAP Crystal Reports | Data base reporting software |
| SoftMed ChartRelease | Data base reporting software |
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Relevant Certifications
Industry certifications that may be valuable for this career role:
| Certification | Issuing Organization | Practice Test |
|---|---|---|
| Board Certified Home Health - Coding | National Credentialing Board of Home Health and Hospice | Not Available |
| Certified Ambulatory Surgery Center Coder | American Academy of Professional Coders | Not Available |
| Certified Anesthesia and Pain Management Coder | American Academy of Professional Coders | Not Available |
| Certified Cardiology Coder | American Academy of Professional Coders | Not Available |
| Certified Coding Associate | American Health Information Management Association | Not Available |
| Certified ENT Coder | American Academy of Professional Coders | Not Available |
| Certified Emergency Department Coder | American Academy of Professional Coders | Not Available |
| Certified Evaluation and Management Coder | American Academy of Professional Coders | Not Available |
| Certified Family Practice Coder | American Academy of Professional Coders | Not Available |
| Certified Gastroenterology Coder | American Academy of Professional Coders | Not Available |
| Certified General Surgery Coder | American Academy of Professional Coders | Not Available |
| Certified Hematology and Oncology Coder | American Academy of Professional Coders | Not Available |
| Certified Internal Medicine Coder | American Academy of Professional Coders | Not Available |
| Certified Interventional Radiology Cardiovascular Coder | American Academy of Professional Coders | Not Available |
| Certified Medical Coder | Practice Management Institute | Not Available |
| Certified Obstetrics Gynecology Coder | American Academy of Professional Coders | Not Available |
| Certified Orthopaedic Surgery Coder | American Academy of Professional Coders | Not Available |
| Certified Outpatient Coding | American Academy of Professional Coders | Not Available |
| Certified Pediatrics Coder | American Academy of Professional Coders | Not Available |
| Certified Plastic and Reconstructive Surgery Coder | American Academy of Professional Coders | Not Available |
| Certified Professional Coder | American Academy of Professional Coders | Not Available |
| Certified Professional Coder in Dermatology | American Academy of Professional Coders | Not Available |
| Certified Radiology Coder | Radiology Coding Certification Board | Not Available |
| Certified Rheumatology Coder | American Academy of Professional Coders | Not Available |
| Certified Urology Coder | American Academy of Professional Coders | Not Available |
| Electronic Health Record Certification | American Medical Certification Association | Not Available |
| Medical Administrative Assistant Certification | American Medical Certification Association | Not Available |
| Medical Coder & Biller Certification | American Medical Certification Association | Not Available |
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