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.
SOC: 29-2072.00
Common Job Titles
Health Information Technician (Health Information Tech)
Medical Records Clerk
Medical Records Coordinator
Registered Health Information Technician (RHIT)
What You'll Need to Succeed
AI-generated
Key competencies for this occupation at a glance
MindsetUphold patient confidentiality and data privacy standards when handling sensitive medical records in accordance with ethical, legal, and regulatory requirements.
Advanced
KnowledgeClassify medical diagnoses, procedures, and services into standardized coding systems (ICD, CPT, HCPCS) using encoder software and coding databases to ensure accurate reimbursement and compliance.
Proficient
KnowledgeEvaluate medical documentation for completeness, accuracy, and compliance with regulatory requirements in hospital and clinic settings, following HIPAA and healthcare industry standards.
Proficient
KnowledgeGenerate reports and statistical analyses on coding accuracy, reimbursement trends, and documentation quality using database tools such as Microsoft SQL Server, Tableau, and statistical software.
Proficient
KnowledgeValidate coded medical data for accuracy against DRG grouping and billing requirements to support proper reimbursement and prevent claim denials.
Proficient
KnowledgeOrganize medical records filing and retrieval systems using computerized indexing, document management platforms like Laserfiche, and chart tracking software to ensure timely access.
Proficient
KnowledgeApply electronic medical record (EMR) systems and health information management software to compile, process, and maintain patient medical records across multiple platforms including Epic Systems and MEDITECH.
Developing
KnowledgeAnalyze clinical documentation and physician notes to extract appropriate diagnostic and procedural information for coding assignment.
Developing
KnowledgeInterpret medical terminology, anatomy, and pathophysiology within patient records to ensure accurate coding and classification of healthcare services.
Developing
Hands-onOperate document scanning and imaging equipment including barcode scanners, flat-top scanners, and DICOM medical imaging systems to digitize patient records.
Developing
MindsetEngage with healthcare providers and interdisciplinary teams to clarify clinical documentation and resolve coding discrepancies.
Developing
Wage Data According to the Bureau of Labor Statistics
Annual wage data for Medical Records Specialists (2024)
Estimated Total Employment (U.S.)
187,910
Wage Distribution by Percentile
Line chart of annual wages by percentile. U.S. is the solid line. 10th percentile: U.S. $35,780. 25th percentile: U.S. $41,600. 50th percentile: U.S. $50,250. 75th percentile: U.S. $64,070. 90th percentile: U.S. $80,950. Use the left and right arrow keys to move between percentiles.
U.S.
Metric
U.S.
10% of workers earn the following or less
$35,780
10% of workers earn the following or more
$80,950
Workers on average earn
$55,970
+ indicates wage is at or above the BLS reporting cap ($239,200/year)
Tools & Technology
Equipment and software commonly used in this occupation
