Every time a doctor, nurse, or other medical provider performs a test, service, or treatment, it creates a record. Those records are used to keep patient data, communicate with other healthcare providers, and serve as proof-of-service for insurance reimbursement.
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The language medical professionals use to make care notes doesn’t always match up with the language of insurance companies. That’s where medical records specialists play a vital role. A medical records specialist is responsible for maintaining all the data of their healthcare facility. They make sure it’s accurately recorded and then translate that data into codes that are used for insurance reimbursement.
Medical records specialists, sometimes called electronic health record specialists, do more than enter data. They’re responsible for making sure that data can be shared without compromising patient privacy or information accuracy. And as technology continues to change the face of healthcare, medical records specialists’ jobs have grown increasingly important.
The changing landscape of healthcare is creating an increased need for medical records specialists.
“Certainly, as the landscape of healthcare is changing at a dizzying pace, the need for proper clinical documentation and maintenance of patient records has become more essential than ever,” says Sareer Zia, MD, MBA, and a physician advisor for a documentation, medical billing, and coding department at SIH Herrin Hospital, in Herrin, Illinois. The COVID-19 pandemic has brought an explosion of telehealth services and health tech gadgets such as remote patient monitoring devices. “This resulted in changes in regulations and reimbursement to allow the users to maximize the applications of digital health. This means that if we don’t watch closely what is coming and don’t put guardrails, we will be struck with a tsunami of data, and that’s the area where medical record specialists will be very much needed.”
You’ll need at least a high school diploma and certification to jump into this growing career. Once you have your education, there are numerous job opportunities in hospitals, doctors’ offices, and even the comfort of your own home. Read on to learn more about what you’ll do, what education you’ll need, and what you can earn as a medical records specialist.
What do Medical Records Specialists Do?
Medical records specialists gather, organize, and maintain health information. The information they work with comes from paper records, electronic medical records (EMR), and other electronic systems. As a medical records specialist, you’ll be responsible for checking data for accuracy and translating it into codes that can be used for insurance reimbursement. Your exact duties will vary depending on where you work, but they generally include:
At first glance, this might seem like a predictable desk job, but in truth, that’s not the case. You’ll need to be organized and prepared to take on new challenges to excel in this role.
“One of the many hats (medical records specialists) wear is that of a gatekeeper or watchman; filtering information, removing noise, watching (what) is coming from where, organizing and channeling that information to the right area and the right department, and ensuring the flow of quality information,” Zia explains. “They are not only responsible for overseeing the influx, but also for the outflow of the information, protecting it from any privacy breach or HIPAA violations.”
What’s the Difference Between a Medical Records Specialist and a Medical Biller and Coder?
Medical records specialists and medical billers and coders both work with patient files and records, but there are some key differences. While both jobs involve medical coding for insurance companies, the scope of a medical records specialist is much broader.
Medical coders and billers are focused on billing. They work with insurance companies and submit claims. They also process coverage denials and update patient billing statements. Unlike a medical records specialist, they’re not responsible for maintaining other details of a patient’s medical record.
Where Do They Work?
While most medical records specialists work in hospitals, that’s far from the only place you can find work in this career. Other places you can find work as a medical records specialist include:
No matter where you work, you’ll play a huge role in the success of your company.
“They are a vital part of any healthcare organization,” says Zia. “The framework of healthcare heavily relies on medical records, which are like the building blocks of medicine, and medical record specialists are the caretakers of those building blocks.”
You might find higher pay and more room for advancement in some workplaces. For example, medical records technicians working for insurance companies make about $4,000 more each year than those working in hospitals, according to data from the U.S. Bureau of Labor Statistics (BLS). Factors such as your education, certification, and experience will also influence your salary.
Can I Do This Job from Home?
This role is largely computer-based, and many medical records technicians can work from home. If you have kids at home, you live far from your employer, or you’re juggling a job and school at the same time, a role like this—as long as it offers flexible hours—might be a great fit. Large insurance carriers and health systems are more likely to have medical records jobs that can be done at home. Smaller employers such as doctors’ offices and nursing facilities will likely need you to work in-house.
Since the job of medical records specialist is largely computer-based, some employers may offer flexible hours and the ability to work from home.
How to Become a Medical Records Specialist
As a rule, you’ll need to earn at least a certificate to work as a medical records specialist. While some medical records specialist jobs are available to people with only a high school diploma and experience, most employers will ask that you have education in the field.
You can earn a certificate, an associate degree, or even a bachelor’s degree in the field. As with most jobs, earning a higher degree will open doors for more career advancement and higher salaries.
Minimum Education Requirements
It’s a good choice to start your career by completing a certificate program or an associate degree. There are a few different degree tracks that can help you prepare for this role.
You can find certificates and degrees that will help you learn what you need to work as a medical records specialist at community colleges and technical schools. Programs might have different names, depending on your school. No matter the degree track you take, you’ll need to make sure it includes coursework in both medical terminology and medical coding.
“(Medical records specialists need) an understanding of common medical terminology, knowledge about payers, regulations, reimbursement, and ICD-10 (the WHO-maintained International Classification of Diseases),” Zia said.
What Will I Learn?
Your exact courses will depend on your school and your degree track. You will need some health and science courses to take on a medical records specialist role. While you won’t go as in-depth as some other healthcare professionals, you will need to learn enough to understand doctors’ notes and other medical records and be able to translate them into insurance coding. Common courses include:
You’ll also need to be able to take what you’ve learned and use it to be adaptable and flexible. As technology changes, your job as a medical records specialist will change some along with it. For example, in the past, doctors and nurses wrote notes by hand and medical records specialists then entered the data into computer coding. Today, doctors type their notes in EHR, but that doesn’t mean that there is less need for medical records technicians.
Many in the industry have concerns that artificial intelligence and machine learning will take away many jobs in healthcare, Zia says. “That is actually good news, especially with data that is flooding healthcare organizations,” she says. “It means that medical records specialists can then focus on more specialized tasks that machines can’t do, and that includes quality assurance, collaboration, communication, and all the people skills that machines don’t possess. And that is where adaptability will be much needed.”
How Long Does It Take?
The length of time it will take to complete your education depends on your degree, whether you go to school full or part time, and the college credits you already have. But in general:
Certificate program: Less than a year
Associate degree: Two years
Bachelor’s degree: Four years
Can I Take Classes Online?
Yes. Many schools offer online programs for this career track. Most programs don’t require any fieldwork, so you can complete the entire program online.
Certifications and Licensure
While many healthcare careers require licensure, you don’t need a license to work as a medical records specialist. There are also no required certifications in the field. However, there are optional certifications that can make you stand out to employers and might help you advance your career.
To clarify: Certification is different than the certificate you earn from a certificate program. While it’s easy to confuse the two, a certificate program is an educational path to working in the field, and certification is a credential you can earn through testing that demonstrates your knowledge.
Optional certifications for medical records technicians are available from American Health Information Management Association (AHIMA) and the National Healthcareer Association (NHA).
A “certificate” program is an educational path; “certification” is a credential you can earn through testing to demonstrate knowledge and advance in your field.
One of the most popular certifications for medical records technicians is the Registered Health Information Technician (RHIT) certification from AHIMA. You’ll need at least an associate degree to apply for this certification. If you don’t have an associate, you can go for the Certified Electronic Health Records Specialist (CEHRS) from NHA.
The BLS doesn’t track data specifically for medical records specialists, but it does include it under the larger umbrella of medical records and health information specialists. According to the BLS, professionals in this group earned a median wage of $44,090 in 2020. Salaries can vary depending on where you work. For example, medical records specialists with roles in business management earned a median annual salary of $50,010, while medical records specialists who worked in the offices of physicians made a lower median wage of $39,190.
The BLS reports that medical records specialist roles are growing. The career is expected to grow 8% by 2029, a rate that matches what Zia has observed in the field.
“The need for proper clinical documentation and maintenance of medical records has never been more essential,” she says. While technology like electronic health records is meant to make medical record-keeping tasks simple, it has simultaneously introduced different methods of capturing medical information, which can lead to human error. The same goes for shifts in clinical documentation. Medical records specialists are responsible for ensuring new regulations are followed and that data is handled appropriately.
“Given the fluidity of the healthcare industry with all the changes in reimbursement, rules, regulations, and policies, it’s hard for physicians to keep track of all these in addition to the advances that are happening in the field of medicine and health tech daily,” Zia says. “Hence, it has become crucial for the medical records specialist to know how to navigate these EMRs and understand the intricacies of the dynamic healthcare industry and stay on top of these changes in documentation to ensure the consistency, accuracy, and quality of medical records.”
Any role that is heavily based on technology is likely to change fast, and medical records specialist careers are no exception. It’s important to stay on top of new developments in the field. Some great resources to help you keep up with changes and advance your career include: