What does a Medical Records Specialist do?
Published 4 min read
A medical records specialist is responsible for organizing and maintaining patient medical records. They may also be responsible for transcribing doctors’ notes and filing insurance claims.
Medical Records Specialist job duties include:
- Maintain medical records in both paper and electronic formats
- Review and verify accuracy of medical records
- Code diagnoses and procedures using ICD-10-CM and CPT coding systems
- Abstract pertinent information from medical records for inclusion in patient’s permanent record
- Release medical records to authorized individuals and agencies in accordance with HIPAA regulations
- Maintain confidentiality of patient information at all times
- Assist with audits of medical records as needed
- Prepare statistical reports as requested
- Perform other duties as assigned
Medical Records Specialist Job Requirements
A medical records specialist is responsible for organizing and maintaining patient medical records. They may also be responsible for coding diagnoses and procedures, as well as managing release of information requests. A medical records specialist typically needs at least an associate's degree in health information management, although some jobs may require a bachelor's degree. Certification through the American Health Information Management Association (AHIMA) is also often required. Previous experience working in a medical office or hospital is also helpful.
Medical Records Specialist Skills
- Record keeping
- Filing
- Data entry
- Microsoft Office
- ICD-9 and CPT coding
- Medical terminology
- HIPAA compliance
- Patient confidentiality
- Time management
- Organizational skills
- Attention to detail
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How to become a Medical Records Specialist
A medical records specialist is responsible for organizing and maintaining patient medical records. They may also be responsible for coding diagnoses and procedures, as well as transcribing physician orders. A medical records specialist typically works in a hospital or doctor’s office, but can also work for a health insurance company or other healthcare organization.
To become a medical records specialist, you will need at least a high school diploma, although some employers may prefer candidates with an associate’s degree or higher. You will also need to be proficient in computer applications and have strong organizational skills. Many medical records specialists complete on-the-job training, which can last up to several months. Some employers may also require certification from the American Health Information Management Association (AHIMA).
If you are interested in becoming a medical records specialist, start by researching educational programs that can help you develop the skills and knowledge needed for the job. Once you have completed your education, look for entry-level positions in hospitals or doctor’s offices. Be sure to highlight your computer and organizational skills on your resume and during interviews. Once you have gained some experience, you may want to consider pursuing certification from AHIMA to improve your career prospects.
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