Medical Records or Health Information Specialist

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Salary Range: $40,000 to $59,999

Average Hourly: $ 21.75

Education: Postsecondary nondegree award

Number of Jobs: 416400

Jobs Added to 2029: 37100

Growth: As fast as average



Go here to see salary and job data specific to the United Kingdom.

What Medical Records and Health Information Specialists Do

Medical records and health information specialists organize, manage, and code health information data. They use various classification systems to code and categorize patient information for insurance reimbursement purposes, for databases and registries, and to maintain patients’ medical and treatment histories.

Duties

Medical records and health information specialists typically do the following:

  • Review patients’ records for timeliness, completeness, and accuracy
  • Organize and update information in clinical databases or registries
  • Use classification systems to assign clinical codes for insurance reimbursement and data analysis
  • Electronically record data for collection, storage, analysis, retrieval, and reporting
  • Maintain confidentiality of patients’ records

Medical records and health information specialists verify and validate patients’ health information, including their medical history, symptoms, examination and test results, treatments, and other information about healthcare services provided to patients. Their duties vary by employer and by the size of the facility in which they work.

Although medical records and health information specialists do not provide direct patient care, they work regularly with registered nurses and other healthcare workers. They meet with these workers to clarify diagnoses or to get additional information.

Medical records and health information specialists use electronic health records (EHRs) software, following EHR security and privacy practices to analyze electronic data and improve healthcare information.

The following are examples of types of medical records and health information specialists:

Cancer registrars review patients’ records and pathology reports to verify completeness and accuracy. They assign classification codes to represent the diagnosis and treatment of cancers and benign tumors. Cancer registrars conduct annual followups to track treatment, survival, and recovery. They compile and analyze cancer patient information for research purposes, and they maintain facility, regional, and national databases of cancer patients.

Health information technicians collect, analyze, and track treatment and followup information on patients. They respond to record requests and validate authorizations and other legal requests. These technicians also provide administrative support to other staff in the health information management department.

Medical coders assign the diagnosis and procedure codes for patient care, population health statistics, and billing purposes. For example, they might review patient information for preexisting conditions, such as diabetes, to ensure proper coding of patient data. They also work as the liaison between healthcare providers and billing offices.


Work Environment

Medical records and health information specialists typically spend many hours at a computer. Most work full time.


Work Environment Details

Health information technologists, medical registrars, surgical assistants, and healthcare practitioners and technical workers, all other held about 81,400 jobs in 2020. The largest employers of health information technologists, medical registrars, surgical assistants, and healthcare practitioners and technical workers, all other were as follows:
General medical and surgical hospitals; state, local, and private 33%
Offices of physicians 10
Educational services; state, local, and private 7
Federal government 6
Professional, scientific, and technical services 5

Medical dosimetrists, medical records specialists, and health technologists and technicians, all other held about 335,000 jobs in 2020. The largest employers of medical dosimetrists, medical records specialists, and health technologists and technicians, all other were as follows:

General medical and surgical hospitals; state, local, and private 33%
Outpatient care centers 16
Offices of physicians 14
Administrative and support services 5
Government 5

Medical records and health information specialists typically work at a computer.

Work Schedules

Most medical records and health information specialists work full time. In healthcare facilities that are always open, such as hospitals, specialists may work evening or overnight shifts.


Job Outlook

Overall employment of medical records and health information specialists is projected to grow 9 percent from 2020 to 2030, about as fast as the average for all occupations.

About 34,300 openings for medical records and health information specialists are projected each year, on average, over the decade. Many of those openings are expected to result from the need to replace workers who transfer to different occupations or exit the labor force, such as to retire.


How to Become a Medical Records or Health Information Specialist

Medical records and health information specialists typically need a postsecondary certificate to enter the occupation, although some qualify with a high school diploma. Others need an associate’s or higher degree. Certification is often required.

Education

A high school diploma or equivalent and experience in a healthcare setting are enough to qualify for some positions, but others require postsecondary education.

Postsecondary certificate and degree programs in health information technology typically include courses in medical terminology, health data requirements and standards, and classification and coding systems. Applicants may increase their chances of admission by taking high school courses in health, computer science, math, and biology.

Licenses, Certifications, and Registrations

Employers may prefer to hire medical records and health information specialists who have certification, or they may expect applicants to earn certification shortly after being hired. Certifications available for medical records and health information specialists include the Certified Professional Coder (CPC), the Certified Coding Associate (CCA), and the Registered Health Information Technician (RHIT).

Some certifications require candidates to pass an exam. Others require graduation from an accredited program. Many coding certifications also require coding experience in a work setting. Once certified, specialists typically must renew their certification regularly and take continuing education courses.

A few states and facilities require cancer registrars to be certified. Certification as a Certified Tumor Registrar (CTR) requires completion of a formal education program and experience, along with passing an exam.

Advancement

Specialists may advance to become medical or health services managers after completing a higher certification program or earning a bachelor’s or master’s degree in health information technology. Requirements vary by facility.

Important Qualities

Analytical skills. Medical records and health information specialists must interpret medical documentation to assess diagnoses, which they then code into a patient’s medical records.

Detail oriented. Medical records and health information specialists must be precise about verifying and coding patient information.

Integrity. Medical records and health information specialists must exercise discretion and act ethically when working with patient data to protect patient confidentiality, as required by law.

Interpersonal skills. Medical records and health information specialists need to be able to discuss patient information, discrepancies, and data requirements with physicians, finance personnel, and other workers involved in patient care and recordkeeping.


United Kingdom Job Data

Source:

Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Medical Records and Health Information Specialists, at https://www.bls.gov/ooh/healthcare/medical-records-and-health-information-technicians.htm (visited ).