Medical Records Specialists

Medical records specialists compile, process, and maintain patient files. They also may classify and enter patients’ medical information into the healthcare industry's numerical coding system.

Duties

Medical records specialists typically do the following:

• Review patients’ records for timeliness, completeness, and accuracy
• Use classification systems to assign clinical codes for patients’ diagnoses, procedures, medical services, and related information
• Maintain and retrieve records for insurance reimbursement and data analysis
• Electronically record data for collection, storage, analysis, retrieval, and reporting
• Ensure confidentiality of patients’ records

Medical records specialists have a variety of data entry and recordkeeping tasks. They may gather patients’ medical histories, symptoms, test results, treatments, and other health information and enter the details into electronic health records (EHR) systems. Some workers categorize medical information for purposes such as insurance reimbursement and providing data to clinicians.

When handling medical records, these workers follow administrative, ethical, and legal requirements for safeguarding patient privacy. Medical records specialists also may serve as gatekeepers for access to patient files. They ensure access only to authorized people and retrieve, scan, and transmit files according to established protocols.   

Medical coders assign the diagnosis and procedure codes for patient care, population health statistics, and billing purposes. For example, they might review patient information for preexisting conditions, such as diabetes, to ensure proper coding of patient data. They also work as the liaison between healthcare providers and billing offices.

Although medical records specialists do not provide direct patient care, they work regularly with registered nurses and other healthcare workers. They meet with these workers to clarify diagnoses or to get additional information.

For information about other workers who deal with healthcare records, see the profile for health information technologists and medical registrars.

Medical records specialists held about 194,800 jobs in 2024. The largest employers of medical records specialists were as follows:

Medical records specialists typically work at a computer.

Work Schedules

Most medical records specialists work full time. In healthcare facilities that are always open, such as hospitals, specialists may work shifts, including nights or weekends.

Medical records specialists typically need a postsecondary certificate to enter the occupation, although some qualify with a high school diploma. Others might need an associate’s or bachelor's degree. Certification may be required or preferred.

The median annual wage for medical records specialists was $50,250 in May 2024.

Employment of medical records specialists is projected to grow 7 percent from 2024 to 2034, much faster than the average for all occupations.

About 14,200 openings for medical records specialists are projected each year, on average, over the decade. Many of those openings are expected to result from the need to replace workers who transfer to different occupations or exit the labor force, such as to retire.