Medical Records Specialist

Also called: Certified Coding Specialist, Certified Medical Coder, Certified Professional Coder (CPC), Clinical Office Technician (Clinical Office Tech), Coder

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Medical records specialists 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.

Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.
Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
Consult classification manuals to locate information about disease processes.
Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
Identify, compile, abstract, and code patient data, using standard classification systems.
Maintain or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.
Post medical insurance billings.
Process and prepare business or government forms.
Process patient admission or discharge documents.
Protect the security of medical records to ensure that confidentiality is maintained.
Release information to persons or agencies according to regulations.
Resolve or clarify codes or diagnoses with conflicting, missing, or unclear information by consulting with doctors or others or by participating in the coding team's regular meetings.
Retrieve patient medical records for physicians, technicians, or other medical personnel.
Review records for completeness, accuracy, and compliance with regulations.
Scan patients' health records into electronic formats.
Schedule medical appointments for patients.
Transcribe medical reports.

Work Context

Work Context information for this career will be available soon.

Work Activities

Work Activities information for this career will be available soon.

Detailed Work Activities

Classify materials according to standard systems.
Record patient medical histories.
Maintain medical or professional knowledge.
Enter patient or treatment data into computers.
Collect medical information from patients, family members, or other medical professionals.
Code data or other information.