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.
Technology Tools
Key Tasks
- 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.
- 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.
- 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.
- Review records for completeness, accuracy, and compliance with regulations.
- Scan patients' health records into electronic formats.
- Schedule medical appointments for patients.
- Transcribe medical reports.
- Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
- Consult classification manuals to locate information about disease processes.
- Process and prepare business or government forms.
- Process patient admission or discharge documents.
- Retrieve patient medical records for physicians, technicians, or other medical personnel.
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Interests
Conventional
Work involves following procedures and regulations to organize information or data, typically in a business setting. Conventional occupations are often associated with office work, accounting, mathematics/statistics, information technology, finance, or hum
Investigative
Work involves studying and researching non-living objects, living organisms, disease or other forms of impairment, or human behavior. Investigative occupations are often associated with physical, life, medical, or social sciences, and can be found in the f
Social
Work involves helping, teaching, advising, assisting, or providing service to others. Social occupations are often associated with social, health care, personal service, teaching/education, or religious activities.
Realistic
Work involves designing, building, or repairing of equipment, materials, or structures, engaging in physical activity, or working outdoors. Realistic occupations are often associated with engineering, mechanics and electronics, construction, woodworking, t
Enterprising
Work involves managing, negotiating, marketing, or selling, typically in a business setting, or leading or advising people in political and legal situations. Enterprising occupations are often associated with business initiatives, sales, marketing/advertis
Artistic
Work involves creating original visual artwork, performances, written works, food, or music for a variety of media, or applying artistic principles to the design of various objects and materials. Artistic occupations are often associated with visual arts,
Work Styles
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