Medical records specialists, also called health information technicians, maintain the data files that doctors and nurses need to perform their jobs effectively. Although they don't perform actual patient care, most medical records specialists work in health care facilities or doctors' offices. Their duties partly depend on the type of facility where they work and on whether or not they specialize in a particular area of medical records.
Medical records specialists organize and maintain health information both in paper files and in electronic systems. They check data for accuracy, assign codes for insurance reimbursement, record information and keep file folders and electronic databases up-to-date. Some of the data they manage includes patient information, medical histories, physician exams, test results, treatments and services provided. In addition to their clerical duties, records specialists often consult with health care professionals to make sure information is accurate. They must also follow best practices for security and patient confidentiality.
In hospitals and other larger facilities, health information technicians often specialize. For example, coders translate information from doctors into the form necessary for billing by assigning the correct code for each diagnosis and treatment. Coders also need an understanding of heath care and insurance laws and practices to do their jobs properly. Other specialists, called cancer registrars, check the accuracy of cancer patients' records and assign appropriate codes. They check on patient outcomes yearly and compile data that's used for research.
Tools and Technology
Medical records specialists use label printers, bar code scanners and flat-top scanners. They use typical office computer programs, such as word processing, document managing and data base software. They also use special medical classification and categorization software, such as the kind needed to assign the correct codes. Because federal laws encourage more health providers to switch to electronic health records, medical information technicians must know how to use these EHR systems.
Hospitals, doctors' offices, nursing facilities and government agencies are the major employers of medical records specialists, according to the U.S. Bureau of Labor Statistics. Records specialists spend most of their time in an office, usually at the computer. Most work full time, and they may have to work nights and evenings in hospitals and other 24-hour facilities.
A post-secondary certificate or associate degree in medical records technology is the typical job requirement to become a medical records specialist. Some employers prefer candidates who have passed an exam for professional certification, such as the Registered Health Information Technician. The BLS reports that medical records and health information technicians earned an average annual wage of $37,710 as of 2013. The top 10 percent made $57,320 annually or more. The BLS projects a 22 percent increase in employment for this career between 2012 and 2022, which is twice as fast as the average for all jobs.