Medical Records Specialists

What Does a Medical Records Specialists Do?

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.

Day-to-Day Responsibilities

• 1Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.
• 2Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
• 3Consult classification manuals to locate information about disease processes.
• 4Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
• 5Identify, compile, abstract, and code patient data, using standard classification systems.
• 6Maintain or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.
• 7Post medical insurance billings.
• 8Process and prepare business or government forms.

Required Skills

• 3M Encoder
• Allscripts EHR
• Amazing Charts
• American Medical Association CodeManager
• Azalea Health Azalea EHR
• Billing software
• Coding database software
• ComChart EMR
• Computerized indexing systems
• Corel WordPerfect Office Suite

Medical Records Specialists Salary