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Medical Records Specialists

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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)

This title represents an occupation for which data collection is currently underway.

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Tasks  |  Technology Skills  |  Tools Used  |  Detailed Work Activities  |  Job Zone  |  Credentials  |  Wages & Employment  |  Job Openings  |  Additional Information

Tasks

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  • Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.See more occupations related to this task.
  • Compile and maintain patients’ medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.See more occupations related to this task.
  • Consult classification manuals to locate information about disease processes.See more occupations related to this task.
  • Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.See more occupations related to this task.
  • Identify, compile, abstract, and code patient data, using standard classification systems.See more occupations related to this task.
  • Maintain or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.See more occupations related to this task.
  • Post medical insurance billings.See more occupations related to this task.
  • Process and prepare business or government forms.See more occupations related to this task.
  • Process patient admission or discharge documents.See more occupations related to this task.
  • Protect the security of medical records to ensure that confidentiality is maintained.See more occupations related to this task.
  • Release information to persons or agencies according to regulations.See more occupations related to this task.
  • 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.See more occupations related to this task.
  • Retrieve patient medical records for physicians, technicians, or other medical personnel.See more occupations related to this task.
  • Review records for completeness, accuracy, and compliance with regulations.See more occupations related to this task.
  • Scan patients’ health records into electronic formats.See more occupations related to this task.
  • Schedule medical appointments for patients.See more occupations related to this task.
  • Transcribe medical reports.See more occupations related to this task.

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Technology Skills

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  • Accounting software — Billing software; NDCMedisoft; QMSoftware Receivables Management; Siemens Soarian FinancialsSee more occupations related to this technology.
  • Analytical or scientific software — IBM SPSS Statistics Hot technology ; Minitab Hot technology ; SAS Hot technology ; StataCorp StataSee more occupations related to this technology.
  • Business intelligence and data analysis software — IBM Cognos Impromptu Hot technology ; MicroStrategy Hot technology ; Qlik Tech QlikView Hot technology ; Tableau Hot technologySee more occupations related to this technology.
  • Calendar and scheduling software — MD Synergy Medical Appointment Scheduling; Scheduling software; Siemens Soarian SchedulingSee more occupations related to this technology.
  • Categorization or classification software — 3M Encoder; American Medical Association CodeManager; Computerized indexing systems; DRG grouping softwareSee more occupations related to this technology.
  • Data base management system software — Teradata Database Hot technologySee more occupations related to this technology.
  • Data base reporting software — Microsoft SQL Server Reporting Services Hot technology ; SAP Crystal Reports Hot technology ; SoftMed ChartReleaseSee more occupations related to this technology.
  • Data base user interface and query software — Data entry software; Microsoft Access Hot technology ; Microsoft SQL Server Hot technology ; Structured query language SQL Hot technology (see all 9 examples)See more occupations related to this technology.
  • Desktop communications software — EkoSee more occupations related to this technology.
  • Development environment software — Microsoft Visual Basic Hot technology ; Microsoft Visual Basic Scripting Edition VBScript Hot technologySee more occupations related to this technology.
  • Document management software — Hyland Software OnBase; IDX Systems Patient Chart Tracking; SoftMed ChartLocater; SoftMed ChartReserve (see all 6 examples)See more occupations related to this technology.
  • Electronic mail software — Email software; Microsoft Exchange Hot technology ; Microsoft Outlook Hot technologySee more occupations related to this technology.
  • Enterprise application integration software — IBM InfoSphere DataStageSee more occupations related to this technology.
  • Enterprise resource planning ERP software Hot technology — Microsoft Dynamics Hot technology ; SAP Business ObjectsSee more occupations related to this technology.
  • Expert system software — Information Resource Products Clinical Coding ExpertSee more occupations related to this technology.
  • Graphics or photo imaging software — Graphics softwareSee more occupations related to this technology.
  • Information retrieval or search software — Coding database softwareSee more occupations related to this technology.
  • Internet browser software — Web browser softwareSee more occupations related to this technology.
  • Medical software — Epic Systems Hot technology ; Healthcare common procedure coding system HCPCS Hot technology ; Henry Schein Dentrix Hot technology ; Medical condition coding software Hot technology (see all 40 examples)See more occupations related to this technology.
  • Metadata management software — CA Erwin Data ModelerSee more occupations related to this technology.
  • Network security and virtual private network VPN equipment software — Virtual private networking VPN software Hot technologySee more occupations related to this technology.
  • Object or component oriented development software — R Hot technologySee more occupations related to this technology.
  • Office suite software — Corel WordPerfect; Microsoft Office Hot technologySee more occupations related to this technology.
  • Operating system software — Microsoft Windows Hot technologySee more occupations related to this technology.
  • Optical character reader OCR or scanning software — Scantron imaging softwareSee more occupations related to this technology.
  • Presentation software — Microsoft PowerPoint Hot technologySee more occupations related to this technology.
  • Process mapping and design software — Microsoft Visio Hot technologySee more occupations related to this technology.
  • Project management software — Microsoft Project Hot technologySee more occupations related to this technology.
  • Spreadsheet software — IBM Lotus 1-2-3; Microsoft Excel Hot technologySee more occupations related to this technology.
  • Transaction security and virus protection software — Encoder softwareSee more occupations related to this technology.
  • Voice recognition software — Cyber Records MediChart Express; ScanSoft Naturally Speaking; Speech recognition software; Voice dictation softwareSee more occupations related to this technology.
  • Word processing software — Microsoft Word Hot technologySee more occupations related to this technology.

Hot technology Hot Technology — a technology requirement frequently included in employer job postings.

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Detailed Work Activities

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  • Perform clerical work in medical settings.See more occupations related to this activity.
  • Process healthcare paperwork.See more occupations related to this activity.
  • Classify materials according to standard systems.See more occupations related to this activity.
  • Code data or other information.See more occupations related to this activity.
  • Collect medical information from patients, family members, or other medical professionals.See more occupations related to this activity.
  • Communicate with management or other staff to resolve problems.See more occupations related to this activity.
  • Enter patient or treatment data into computers.See more occupations related to this activity.
  • Maintain medical facility records.See more occupations related to this activity.
  • Maintain medical or professional knowledge.See more occupations related to this activity.
  • Maintain security.See more occupations related to this activity.
  • Monitor medical facility activities to ensure adherence to standards or regulations.See more occupations related to this activity.
  • Prepare official health documents or records.See more occupations related to this activity.
  • Process medical billing information.See more occupations related to this activity.
  • Record patient medical histories.See more occupations related to this activity.
  • Schedule appointments.See more occupations related to this activity.
  • Schedule patient procedures or appointments.See more occupations related to this activity.

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Job Zone

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, travel guides, electricians, agricultural technicians, barbers, court reporters, and medical assistants.
SVP Range (6.0 to < 7.0)

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Credentials

Find Training Find Certifications Find Licenses Apprenticeship.gov

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Wages & Employment Trends

Median wage data for Medical Dosimetrists, Medical Records Specialists, and Health Technologists and Technicians, All Other.
Employment data for Medical Dosimetrists, Medical Records Specialists, and Health Technologists and Technicians, All Other.
Industry data for Medical Dosimetrists, Medical Records Specialists, and Health Technologists and Technicians, All Other.

Median wages (2020) $21.20 hourly, $44,090 annual
State wages
 
Local wages
  
Employment (2020) 335,000 employees
Projected growth (2020-2030) Average (5% to 10%) Average (5% to 10%)
Projected job openings (2020-2030) 27,400
State trends
 
Top industries (2020)
Health Care and Social Assistance

Source: Bureau of Labor Statistics 2020 wage data external site and 2020-2030 employment projections external site. “Projected growth” represents the estimated change in total employment over the projections period (2020-2030). “Projected job openings” represent openings due to growth and replacement.

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Job Openings on the Web

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Sources of Additional Information

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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.

  • AAPC external site
  • American Health Information Management Association external site
  • Medical Billing and Coding external site
  • National Cancer Registrars Association external site
  • National Healthcareer Association external site
  • Occupational Outlook Handbook: Medical records and health information specialists external site

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This page includes information from O*NET OnLine by the U.S. Department of Labor, Employment and Training Administration (USDOL/ETA). Used under the CC BY 4.0 license. O*NET® is a trademark of USDOL/ETA.

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