Medical Records and Health Information Technicians

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Medical Records and Health Information Technicians

Careers / Medical Records and Health Information Technicians

Summary Description


	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 health care system. Process, maintain, compile, and report patient information for health requirements and standards in a manner consistent with the healthcare industry's numerical coding system.

Sample Job Titles

1.	Applications Analyst

2.	Business Office Representative

3.	Cancer Registrar

4.	Certified Coding Specialist

5.	Certified Medical Coder

6.	Certified Professional Coder (CPC)

7.	Clinical Analyst

8.	Clinical Data Specialist

9.	Clinical Documentation Improvement Specialist (CDIS)

10.	Clinical Office Technician

11.	Coder

12.	Compliance Coordinator

13.	Disability Rater

14.	Health Data Analyst

15.	Health Informatics Specialist

16.	Health Information Administrator

17.	Health Information Clerk

18.	Health Information Coder

19.	Health Information Management Hospital Coder (HIM Hospital Coder)

20.	Health Information Management Technician

21.	Health Information Specialist

22.	Health Information Systems Technician

23.	Health Information Technician (Health Information Tech)

24.	Health Record Technician

25.	Health Services Information Specialist

26.	Health Unit Clerk

27.	Historian

28.	Hospital Unit Clerk

29.	ICD-9 Coder (International Classification of Diseases Coder)

30.	Insurance Coder

31.	Library Historian

32.	Medical Administrative Specialist

33.	Medical Administrative Technician

34.	Medical Biller Coder

35.	Medical Billing and Coding Specialist

36.	Medical Billing Coder

37.	Medical Billing Specialist

38.	Medical Care Evaluation Specialist

39.	Medical Claims Processor

40.	Medical Coding Technician

41.	Medical Data Analyst

42.	Medical Insurance Coder

43.	Medical Insurance Coding Specialist

44.	Medical Office Technician

45.	Medical Record Assistant

46.	Medical Record Coder

47.	Medical Record Consultant

48.	Medical Record Specialist

49.	Medical Records Analyst

50.	Medical Records Clerk

51.	Medical Records Coordinator

52.	Medical Records Custodian

53.	Medical Records Director

54.	Medical Records Supervisor

55.	Medical Records Technician (Medical Records Tech)

56.	Medical Reimbursement Specialist

57.	Public Health Registrar

58.	Registered Health Information Technician (RHIT)

59.	Release of Information Specialist

60.	Severity of Illness Coordinator

61.	Tumor Registrar

Job Tasks

	Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.

	Protect the security of medical records to ensure that confidentiality is maintained.

	Review records for completeness, accuracy, and compliance with regulations. Monitor medical facility activities to ensure adherence to standards or regulations.

	Process patient admission or discharge documents. Process healthcare paperwork.

	Transcribe medical reports. Perform clerical work in medical settings.

	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.

	Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer. Enter patient or treatment data into computers.

	Identify, compile, abstract, and code patient data, using standard classification systems.

	Retrieve patient medical records for physicians, technicians, or other medical personnel. Perform clerical work in medical settings.

	Release information to persons or agencies according to regulations. Perform clerical work in medical settings.

	Plan, develop, maintain, or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information. Maintain medical facility records.

	Prepare statistical reports, narrative reports, or graphic presentations of information, such as tumor registry data for use by hospital staff, researchers, or other users. Present medical research reports.

	Post medical insurance billings. Process medical billing information.

	Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts. Record patient medical histories.

	Manage the department or supervise clerical workers, directing or controlling activities of personnel in the medical records department. Supervise medical support personnel. Manage healthcare operations.

	Compile medical care and census data for statistical reports on diseases treated, surgery performed, or use of hospital beds.

	Train medical records staff. Train caregivers or other non-medical personnel.

	Process and prepare business or government forms. Prepare official health documents or records. Process healthcare paperwork.

	Consult classification manuals to locate information about disease processes. Maintain medical or professional knowledge.

	Develop in-service educational materials. Prepare healthcare training materials.

Work Activities

Importance	Work Activity

Getting Information — Observing, receiving, and otherwise obtaining information from all relevant sources.

Processing Information — Compiling, coding, categorizing, calculating, tabulating, auditing, or verifying information or data.

Documenting/Recording Information — Entering, transcribing, recording, storing, or maintaining information in written or electronic/magnetic form.

Interacting With Computers — Using computers and computer systems (including hardware and software) to program, write software, set up functions, enter data, or process information.

Organizing, Planning, and Prioritizing Work — Developing specific goals and plans to prioritize, organize, and accomplish your work.

Communicating with Supervisors, Peers, or Subordinates — Providing information to supervisors, co-workers, and subordinates by telephone, in written form, e-mail, or in person.

Updating and Using Relevant Knowledge — Keeping up-to-date technically and applying new knowledge to your job.

Establishing and Maintaining Interpersonal Relationships — Developing constructive and cooperative working relationships with others, and maintaining them over time.

Evaluating Information to Determine Compliance with Standards — Using relevant information and individual judgment to determine whether events or processes comply with laws, regulations, or standards.

Performing Administrative Activities — Performing day-to-day administrative tasks such as maintaining information files and processing paperwork.

Analyzing Data or Information — Identifying the underlying principles, reasons, or facts of information by breaking down information or data into separate parts.

Identifying Objects, Actions, and Events — Identifying information by categorizing, estimating, recognizing differences or similarities, and detecting changes in circumstances or events.

Communicating with Persons Outside Organization — Communicating with people outside the organization, representing the organization to customers, the public, government, and other external sources. This information can be exchanged in person, in writing, or by telephone or e-mail.

Monitor Processes, Materials, or Surroundings — Monitoring and reviewing information from materials, events, or the environment, to detect or assess problems.

Making Decisions and Solving Problems — Analyzing information and evaluating results to choose the best solution and solve problems.

Interpreting the Meaning of Information for Others — Translating or explaining what information means and how it can be used.

Thinking Creatively — Developing, designing, or creating new applications, ideas, relationships, systems, or products, including artistic contributions.

Assisting and Caring for Others — Providing personal assistance, medical attention, emotional support, or other personal care to others such as coworkers, customers, or patients.

Developing and Building Teams — Encouraging and building mutual trust, respect, and cooperation among team members.

Training and Teaching Others — Identifying the educational needs of others, developing formal educational or training programs or classes, and teaching or instructing others.

Coordinating the Work and Activities of Others — Getting members of a group to work together to accomplish tasks.

Performing General Physical Activities — Performing physical activities that require considerable use of your arms and legs and moving your whole body, such as climbing, lifting, balancing, walking, stooping, and handling of materials.

Scheduling Work and Activities — Scheduling events, programs, and activities, as well as the work of others.

Guiding, Directing, and Motivating Subordinates — Providing guidance and direction to subordinates, including setting performance standards and monitoring performance.

Judging the Qualities of Things, Services, or People — Assessing the value, importance, or quality of things or people.

Handling and Moving Objects — Using hands and arms in handling, installing, positioning, and moving materials, and manipulating things.

Performing for or Working Directly with the Public — Performing for people or dealing directly with the public. This includes serving customers in restaurants and stores, and receiving clients or guests.

Coaching and Developing Others — Identifying the developmental needs of others and coaching, mentoring, or otherwise helping others to improve their knowledge or skills.

Resolving Conflicts and Negotiating with Others — Handling complaints, settling disputes, and resolving grievances and conflicts, or otherwise negotiating with others.

Provide Consultation and Advice to Others — Providing guidance and expert advice to management or other groups on technical, systems-, or process-related topics.

Nature of the Work


	(Abstract from Career Articles)

	Medical Records and Health Information Technicians
	Medical records and health information technicians, commonly referred to as health information technicians, organize and manage health information data. They ensure that the information maintains its quality, accuracy, accessibility, and security in both paper files and electronic systems. They use various classification systems to code and categorize patient information for insurance reimbursement purposes, for databases and registries, and to maintain patients' medical and treatment histories.

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Working Conditions


	(Abstract from Career Articles)

	Medical Records and Health Information Technicians
	Health information technicians held about 188,600 jobs in 2014. Most health information technicians work in hospitals or physicians' offices.

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