Medical Records Specialists

Also known as: Certified Coding Specialist, Certified Medical Coder, Certified Professional Coder (CPC) (+46 more)

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.

🎓 Experience Level 3 (Medium preparation needed) 📈 Healthcare & Human Services

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What You'll Do

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.
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.

Essential Skills

Reading Comprehension 3.62/5

Critical Thinking 3.38/5

Active Listening 3.25/5

Writing 3.12/5

Speaking 3.12/5

Time Management 3.12/5

Active Learning 3.0/5

Monitoring 3.0/5

Social Perceptiveness 3.0/5

Service Orientation 3.0/5

Complex Problem Solving 3.0/5

Judgment and Decision Making 3.0/5

Career Fit Overview

Use this summary to understand the kind of profile this role rewards. It helps you judge whether this career looks like a stronger match than your current role, a nearby move worth exploring, or a broader path to compare more seriously.

Top passions

Organizer: Bringing order to data and processes satisfies you.
Analyst: Investigating problems and finding patterns keeps you engaged.
Helper: Supporting people and making a difference matters to you.

Common styles

Attention to Detail, Dependability, Integrity, Cautiousness, Cooperation

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Key Abilities

This career demands strong capabilities in the following areas:

Written Comprehension 3.88/5

Oral Comprehension 3.75/5

Near Vision 3.62/5

Information Ordering 3.5/5

Category Flexibility 3.5/5

Oral Expression 3.38/5

Written Expression 3.25/5

Speech Recognition 3.25/5

Technologies & Tools

NDCMedisoft QMSoftware Receivables Management Siemens Soarian Financials IBM SPSS Statistics Minitab SAS StataCorp Stata Billing software IBM Cognos Impromptu MicroStrategy Qlik Tech QlikView Tableau MD Synergy Medical Appointment Scheduling Scheduling software Siemens Soarian Scheduling 3M Encoder American Medical Association CodeManager Computerized indexing systems DRG grouping software Teradata Database

Work Environment & Strengths

Common Strengths for This Career

Attention to Detail (High importance: 5.0/5)
Dependability (High importance: 4.77/5)
Integrity (High importance: 4.55/5)
Cautiousness (High importance: 4.45/5)
Cooperation (High importance: 4.09/5)

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How to Become One

This career typically requires vocational school, related on-the-job experience, or an associate's degree. Some specialized training or certification may also be required.

Similar Careers to Explore

Also Known As

This career is known by many different job titles across industries. Here are all the variations:

Certified Coding Specialist Certified Medical Coder Certified Professional Coder (CPC) Clinical Documentation Specialist Coder Coding Consultant Coding Specialist Disability Rater EHR Specialist (Electronic Health Records Specialist) Fee Coder HIM Clerk (Health Information Management Clerk) HIM Hospital Coder (Health Information Management Hospital Coder) HIM Inpatient Coding Auditor (Health Information Management Inpatient Coding Auditor) HIM Tech (Health Information Management Technician) Health Informatics Specialist Health Information Clerk Health Information Coder Health Information Specialist Health Information Technician (Health Information Tech) Health Records Specialist Health Records Technician (Health Records Tech) Health Services Information Specialist Inpatient Coder Insurance Coder Medical Administrative Specialist Medical Administrative Technician (Medical Administrative Tech) Medical Bill Coder Medical Biller Medical Billing Coder Medical Billing Specialist Medical Coder Medical Coding Specialist Medical Coding Technician (Medical Coding Tech) Medical Insurance Coder Medical Insurance Coding Specialist Medical Office Coordinator Medical Office Specialist Medical Office Technician (Medical Office Tech) Medical Records Assistant Medical Records Clerk Medical Records Coder Medical Records Custodian Medical Records Technician (Medical Records Tech) Medical Reimbursement Specialist Outpatient Coder Patient Administration Specialist RHIT (Registered Health Information Technician) ROI Medical Records Specialist (Release of Information Medical Records Specialist) ROI Specialist (Release of Information Specialist)

Career Fit FAQs

Is this career a good fit for me

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Can this help if I want to stay in my field

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What should I compare first

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