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Medical Records Specialist

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AVG. SALARY

$49,780

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EDUCATION

1-2 years post-secondary training

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JOB OUTLOOK

Stable

What They Do

Medical Records Specialists Career Video

About This Career

Compiles, processes, and maintains medical records of hospital and clinic patients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the healthcare system. Classifies medical and healthcare concepts, including diagnosis, procedures, medical services, and equipment, into the healthcare industry's numerical coding system.

This career is part of the Health Science cluster Health Informatics pathway.

A person in this career:

  • Assigns the patient to diagnosis-related groups (DRGs), using appropriate computer software.
  • Compiles and maintains patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
  • Consults classification manuals to locate information about disease processes.
  • Enters data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
  • Identifies, compiles, abstracts, and codes patient data, using standard classification systems.
  • Maintains or operates a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.
  • Posts medical insurance billings.
  • Processes and prepares business or government forms.
  • Processes patient admission or discharge documents.
  • Protects the security of medical records to ensure that confidentiality is maintained.

Working Conditions and Physical Demands

People who do this job report that:

  • You would often handle loads up to 10 lbs., sometimes up to 20 lbs. You might do a lot of walking or standing, or you might sit but use your arms and legs to control machines, equipment or tools.
  • Work in this occupation involves using your hands to hold, control, and feel objects more than one-third of the time
  • Work in this occupation requires being inside most of the time
  • Work in this occupation involves making repetitive motions more than one-third of the time
  • Work in this occupation involves sitting more than one-third of the time

Work Hours and Travel

  • Overtime work

Specialty and Similar Careers

Careers that are more detailed or close to this career:

  • Coder
  • Health Information Clerk
  • Health Information Specialist
  • Health Information Technician (Health Information Tech)
  • Medical Records Clerk — Compiles, verifies, types, and files medical records of hospital or other health care facility.
  • Medical Records Coordinator
  • Medical Records Technician (Medical Records Tech)
  • Registered Health Information Technician (RHIT)
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