Medical Records and Health Information Specialists

Summary

What Medical Records and Health Information Specialists Do About this section

Medical records and health information specialists verify and validate patients' health information, including their medical history, symptoms, and examination and test results.

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 About this section

This is one of the few health-related occupations in which there is no direct hands-on patient care.

Medical records and health information specialists held about 341,600 jobs in 2019. The largest employers of medical records and health information specialists were as follows:

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.

How to Become a Medical Records or Health Information Specialist About this section

Medical records and health information specialists organize and update information in clinical databases or registries.

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.

Pay About this section

The median annual wage for medical records and health information specialists was $44,090 in May 2020. The median wage is the wage at which half the workers in an occupation earned more than that amount and half earned less. The lowest 10 percent earned less than $28,800, and the highest 10 percent earned more than $73,370.

In May 2020, the median annual wages for medical records and health information specialists in the top industries in which they worked were as follows:

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 About this section

Employment of medical records and health information specialists is projected to grow 8 percent from 2019 to 2029, much faster than the average for all occupations.

An aging population will require more medical services, and medical records and health information specialists will be needed to organize and manage the older generations’ health information data. This will mean more claims for reimbursement from insurance companies.

Additional records, coupled with widespread use of electronic health records (EHRs) by all types of healthcare providers, will lead to an increased need for specialists to organize and manage the associated information in all areas of the healthcare industry.

Cancer registrars are expected to continue to be in high demand. With an increase in the older population, there will likely be more types of special purpose registries because many illnesses are detected and treated later in life.

State & Area Data About this section

Occupational Employment and Wage Statistics (OEWS)

The Occupational Employment and Wage Statistics (OEWS) program produces employment and wage estimates annually for over 800 occupations. These estimates are available for the nation as a whole, for individual states, and for metropolitan and nonmetropolitan areas. The link(s) below go to OEWS data maps for employment and wages by state and area.

• Medical dosimetrists, medical records specialists, and health technologists and technicians, all other

Projections Central

Occupational employment projections are developed for all states by Labor Market Information (LMI) or individual state Employment Projections offices. All state projections data are available at www.projectionscentral.com. Information on this site allows projected employment growth for an occupation to be compared among states or to be compared within one state. In addition, states may produce projections for areas; there are links to each state’s websites where these data may be retrieved.

CareerOneStop

CareerOneStop includes hundreds of occupational profiles with data available by state and metro area. There are links in the left-hand side menu to compare occupational employment by state and occupational wages by local area or metro area. There is also a salary info tool to search for wages by zip code.

Contacts for More Information About this section

For more information about medical records and health information specialists, including details about certification, visit

American Health Information Management Association

American Academy of Professional Coders

National Healthcareer Association

For more information about cancer registrars, visit

National Cancer Registrars Association

For a list of accredited training programs, visit

Commission on Accreditation for Health Informatics and Information Management Education

CareerOneStop

For a career video on medical records and health information specialists, visit

Medical Records and Health Information Specialists

O*NET

Health Information Technologists and Medical Registrars

Health Technologists and Technicians, All Other

Medical Dosimetrists

Medical Records Specialists

Neurodiagnostic Technologists

Ophthalmic Medical Technologists

Patient Representatives