Occupation · SOC 29-2072
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.
Median wage
$50,250
$35,780–$80,950
Projected growth
+7.1%
Faster than average
Annual openings
1,380
per year
Employed (US)
187,910
Job Zone 3
Typical preparation
Medium preparation
Stackable credential programs
352 mapped
Core skills
Active ListeningCritical ThinkingReading ComprehensionSpeakingSocial PerceptivenessMonitoringJudgment and Decision MakingWriting
Knowledge areas
Medicine and DentistryCustomer and Personal ServiceEnglish LanguageBiologyPsychology
Technology & tools
Categorization or classification softwareMedical softwareBilling and invoicing softwareInformation retrieval or search softwareOffice suite software
Representative tasks
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.
Competency framework
Skill expectations by proficiency level.
emerging
Patient demographic and insurance data — enter and verify under direct supervision within an electronic health record system.Medical record filing protocols — follow established procedures to organize and store paper and digital patient files in a clinical setting.Basic medical terminology and abbreviations — recognize and apply when reviewing patient health histories under guidance.Categorization and classification software — operate under supervision to assign preliminary codes to straightforward patient encounter records.Patient medical histories — collect and record from intake forms using structured templates in a healthcare facility.Office suite and electronic mail software — use to communicate routine records requests between departments following established workflows.Confidentiality and HIPAA privacy rules — identify and adhere to when handling patient information on day one of practice.Information retrieval software — perform basic searches to locate existing patient records in a health information database.Data entry accuracy standards — apply attention-to-detail habits to minimize transcription errors in billing and invoicing fields.Billing and invoicing software — input straightforward charge data under supervision to support the revenue cycle in a medical office.
developing
Patient medical histories — review, compile, and reconcile across multiple encounters with reduced oversight in an outpatient health information department.Diagnostic and procedural codes — assign to routine patient records using classification software and established coding guidelines in a clinical environment.Medical record discrepancies — identify and escalate using critical thinking when reviewing documentation against physician notes in a hospital setting.Voice recognition software output — edit and quality-check transcribed clinical notes to ensure accuracy within a health information workflow.Billing and invoicing records — audit for completeness and coding consistency to reduce claim rejections in a managed care environment.Release-of-information requests — process in compliance with HIPAA regulations and institutional policy with minimal supervisory review.Reading comprehension of clinical documentation — apply to extract relevant diagnostic and treatment data from complex physician reports.Database query software — execute intermediate searches to retrieve, sort, and compile patient data for departmental reporting purposes.Transaction security and virus protection standards — follow established protocols to safeguard electronic health records against unauthorized access.Interdepartmental communication — coordinate records-related inquiries with clinical and billing staff using desktop communications tools and professional written correspondence.
proficient
Patient health information systems — manage end-to-end record integrity across the full patient lifecycle in a multi-provider healthcare organization.Complex or ambiguous medical records — analyze and resolve coding inconsistencies autonomously using advanced classification software and clinical knowledge.Non-routine release-of-information scenarios — evaluate legal and ethical considerations independently to ensure compliant disclosure in sensitive cases.Clinical documentation quality — audit systematically against regulatory and accreditation standards to drive sustained accuracy improvements across a department.Inductive and deductive reasoning — apply to identify systemic documentation patterns that signal billing risk or compliance exposure in a health system.Cross-functional records workflows — redesign and optimize to reduce redundancy and improve turnaround times in a hospital health information department.Staff orientation to records procedures — mentor junior technicians on coding guidelines, privacy rules, and software use in a structured on-the-job setting.Data integrity reporting — produce comprehensive analyses from database query software to support administrative decision-making by departmental leadership.Judgment in ambiguous coding scenarios — exercise independently when existing guidelines do not clearly resolve documentation conflicts in specialty care records.Voice recognition and medical software platforms — troubleshoot and configure to maintain departmental productivity in a high-volume clinical environment.
advanced
Health information governance strategy — develop and implement organization-wide policies that align records management with regulatory, legal, and accreditation requirements.Departmental performance standards — establish measurable benchmarks for coding accuracy, turnaround time, and compliance across a large health information operation.Emerging classification systems and regulatory changes — evaluate and lead adoption planning to ensure organizational readiness across all affected clinical and billing teams.Enterprise health information technology — direct selection, implementation, and optimization of medical records and billing software platforms at the organizational level.Cross-departmental leadership — collaborate with clinical, legal, finance, and IT leaders to align health information practices with institutional strategic goals.Workforce development programs — design and oversee competency-based training curricula that build records specialist skills from entry level through senior practice.Organizational risk exposure — assess and mitigate documentation and privacy vulnerabilities by leading audit programs and reporting findings to executive leadership.Health information data assets — leverage for population health analytics and operational planning by directing advanced database queries and reporting initiatives.Regulatory inspections and accreditation reviews — lead preparation and response efforts, representing the health information function to external bodies.Professional standards advocacy — contribute to industry working groups and mentor future health information leaders to advance the field at a regional or national level.
Also known as
74 alternate job titles map to this occupation.
Medical Records AssistantDental Assistant (Air Force 4Y0X1)Medical CoderHealth Information Systems Technician (Health Information Systems Tech)Health Information ClerkMedical ScribeHealth Information CoderMedical Office Technician (Medical Office Tech)Insurance CoderMedical Records ClerkROI Medical Records Specialist (Release of Information Medical Records Specialist)Medical Records SpecialistMedical Reimbursement SpecialistMedical Insurance Coding SpecialistHealth Records TechnicianMedical Record CoderHealth Information Management Technician (HIM Tech)Fee CoderMedical Record TechnicianMedical Record SpecialistHealth Services Management Manager (Air Force 4A000)Electronic Health Records Specialist (EHR Specialist)Disability RaterDental Assistant Helper (Air Force 4Y011)Health Services Management Superintendent (Air Force 4A091)Coding ConsultantCertified Coding SpecialistHealth Record Technician (Health Record Tech)Health Information Management Hospital Coder (HIM Hospital Coder)Dental Assistant Journeyman (Air Force 4Y051)Medical Records Technician (Medical Records Tech)Medical Administration Specialty (Coast Guard MED)Coding SpecialistHealth Services Systems Management (Army 70D)Medical Records CoordinatorMedical Biller CoderHealth Information Management Inpatient Coding Auditor (HIM Inpatient Coding Auditor)Medical Administrative SpecialistDental Assistant Journeyman, Dental Hygienist (Air Force 4Y051H)Health Information Specialist