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
351 mapped
Core skills
Active ListeningCritical ThinkingReading ComprehensionSpeakingSocial PerceptivenessMonitoringJudgment and Decision MakingWriting
Knowledge areas
Medicine and DentistryCustomer and Personal ServiceEnglish LanguageBiologyPsychology
Technology & tools
3M EncoderAllscripts EHRAmazing ChartsAmerican Medical Association CodeManagerAzalea Health Azalea EHRBilling softwareCoding database softwareComChart EMRComputerized indexing systemsCorel WordPerfect Office SuiteCyber Records MediChart ExpressDRG grouping softwareDigital Imaging Communications in Medicine DICOM medical imaging softwareEHS CareRevolutionEkoElectronic medical record EMR softwareElectronic medical record EMR systemsEmail softwareEncoded archival system EADEncoder softwareEndoSoftEntity Management SoftwareEpic SystemsFox Meadows Accent Data ManagerFox Meadows ChartingPlusFox Meadows EncounterManagerGE Healthcare LogicianGraphics softwareGreenway Medical Technologies PrimeChartHMSHealth Care Data HealthProbeHealthcare common procedure coding system HCPCSHenry Schein DentrixHolt Systems eMedRecHyland Software OnBaseIBM Cognos ImpromptuIBM InfoSphere DataStageIBM Lotus 1-2-3IBM SPSS StatisticsIDX Systems IDXtend
Representative tasks
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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
58 alternate job titles map to this occupation.
Certified Coding SpecialistCertified Medical CoderCertified Professional Coder (CPC)Clinical Documentation SpecialistClinical Office Technician (Clinical Office Tech)CoderCoding ConsultantCoding SpecialistDisability RaterElectronic Health Records Specialist (EHR Specialist)Fee CoderHealth Informatics SpecialistHealth Information ClerkHealth Information CoderHealth 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 SpecialistHealth Information Systems Technician (Health Information Systems Tech)Health Information Technician (Health Information Tech)Health Record Technician (Health Record Tech)Health Records TechnicianHealth Services Information SpecialistInpatient CoderInsurance CoderMedical Administrative SpecialistMedical Administrative Technician (Medical Administrative Tech)Medical Bill CoderMedical BillerMedical Biller CoderMedical Billing CoderMedical Billing SpecialistMedical Claims ProcessorMedical CoderMedical Coding SpecialistMedical Coding Technician (Medical Coding Tech)Medical Front Office SpecialistMedical Insurance CoderMedical Insurance Coding SpecialistMedical Office Coordinator