Medical Records Clerk, Job Description, Salary and How to Be One


medical records clerk how to become one, salary

What Medical Records Clerk Do

Medical records clerk organize and manage health information data by ensuring that it maintains its quality, accuracy, accessibility, and security in both paper files and electronic systems. Go to the full job description.

Medical Records Clerk Salary

A medical records clerk is $46,590 on average as of May 2019. The lowest paid medical records specialists make less than $27,820 and the highest salaries are more than $71,150. See which states and cities pay the most.

How To Become a Medical Records Clerk

You need a high school diploma or GED to be a medical records clerk, although some jobs require some college. You have to be detail-oriented and be able to communicate clearly with a variety of people. This is a good career for the ISTJ personality type. You also need to understand the regulations governing the release of medical information How to become one.

Medical Records Clerk Job Description

Medical records clerks 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.

Other Job Titles

  • Coder
  • Health Information Clerk
  • Health Information Specialist
  • Health Information Technician (Health Information Tech)
  • Medical Records Clerk
  • Medical Records Coordinator
  • Medical Records Technician (Medical Records Tech)
  • Registered Health Information Technician (RHIT)

Medical Records Clerk Duties

  • 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.
  • Post medical insurance billings.
  • 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.
  • 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.
  • Retrieve patient medical records for physicians, technicians, or other medical personnel.
  • Review records for completeness, accuracy, and compliance with regulations.
  • Scan patients’ health records into electronic formats.
  • Schedule medical appointments for patients.
  • Transcribe medical reports.

Also called health information technicians, medical records clerks document patients’ health information, including their medical history, symptoms, examination and test results, treatments, and other information about healthcare services that are provided to patients.

Their duties vary by employer and by the size of the facility in which they work.

Although health information technicians do not provide direct patient care, they work regularly with registered nurses and other healthcare professionals.

They meet with these workers to clarify diagnoses or to get additional information to make sure that records are complete and accurate.

The increasing adaptation and use of electronic health records (EHRs) will continue to change the job responsibilities of medical record clerks will need to be familiar with, or be able to learn, EHR computer software, follow EHR security and privacy practices, and analyze electronic data to improve healthcare information.

Health information technicians can specialize in many aspects of health information.

Some work as medical coders, sometimes called coding specialists, or as cancer registrars.

Medical Coder Job Duties

  • Review patient information for preexisting conditions, such as diabetes, so patient data can be coded properly
  • Assign appropriate diagnoses and procedure codes for patient care, population health statistics, and billing purposes
  • Work as a liaison between the healthcare providers and billing offices

Cancer Registrars Job Duties

  • Review patients’ records and pathology reports to verify completeness and accuracy
  • Assign classification codes to represent the diagnosis and treatment of cancers and benign tumors
  • Conduct annual followups to track treatment, survival, and recovery
  • Compile and analyze cancer patient information for research purposes
  • Maintain facility, regional, and national databases of cancer patients

Medical Records Clerk Salary

A medical records clerk is $46,590 on average as of May 2019. The lowest paid medical records specialists make less than $27,820 and the highest salaries are more than $71,150.

Percentile 10% 25% 50%
(Median) 
75% 90% 
Hourly $13.38$16.23$20.50$26.93$34.21
Annual $27,820$33,760$42,630$56,000$71,150
BLS.gov

Highest Paying States for Medical Records Clerk Jobs

State Hourly
Average 
Annual
Average
District of Columbia $28.58$59,450
Alaska $27.89$58,000
Hawaii $26.41$54,920
Massachusetts $26.14$54,370
Washington $25.91$53,890
BLS.gov
Top paying states for medical records clerk, map of the United States shaded according to salary. The highest medical records clerks are on the west coast

Highest Paying Metro-Areas for Medical Records Clerk Jobs

Metro area Hourly Average SalaryAnnual Average Salary
Salinas, CA $32.37$67,320
Vallejo-Fairfield, CA $31.79$66,120
Kokomo, IN $31.45$65,410
Danbury, CT $30.89$64,240
Kennewick-Richland, WA $30.72$63,900
San Jose-Sunnyvale-Santa Clara, CA $29.28$60,890
Waterbury, CT $29.10$60,530
Sacramento–Roseville–Arden-Arcade, CA $28.78$59,870
Stockton-Lodi, CA $28.71$59,730
Trenton, NJ $28.64$59,570

How to Become a Medical Records Clerk

Education

A high school diploma or equivalent and previous experience in a healthcare setting are enough to qualify for some positions, but most jobs for health information technicians require postsecondary education.

Important Qualities

Analytical skills. Health information technicians must understand and follow medical records and diagnoses, and then decide how best to code them in a patient’s medical records.

Detail oriented. Health information technicians must be accurate when recording and coding patient information.

Integrity. Health information technicians work with patient data that are required, by law, to be kept confidential. They must exercise discretion and a strong sense of ethics when working with this information in order to protect patient confidentiality.

Interpersonal skills. Health information technicians need to be able to discuss patient information, discrepancies, and data requirements with other professionals such as physicians and finance personnel.

Technical skills. Health information technicians must use coding and classification software and the electronic health record (EHR) system that their healthcare organization or physician practice has adopted.

Licenses, Certifications, and Registrations

Most employers prefer to hire health information technicians who have certification, or they may expect applicants to earn certification shortly after being hired.

A health information technician can earn certification from several organizations. Certifications include the Registered Health Information Technician (RHIT) and the Certified Tumor Registrar (CTR), among others.

Some organizations base certification on passing an exam. Others require graduation from an accredited program.

Many coding certifications also require coding experience in a work setting. Once certified, technicians typically must renew their certification regularly and take continuing education courses.

A few states and facilities require cancer registrars to be certified. Certification as a Certified Tumor Registrar (CTR) requires completion of a formal education program and experience, along with passing an exam.

Advancement

Technicians may advance to a position as a medical or health services manager after completing a bachelor’s or master’s degree program and taking the required certification courses. Requirements vary by facility.

For more information about health information technicians, including details about certification, visit

American Health Information Management Association

American Academy of Professional Coders

Professional Association of Healthcare Coding Specialists

National Healthcareer Association

For more information about medical coding and billing, visit

MB&CC (formerly known as Medical Billing & Coding)

For more information about cancer registrars, visit

National Cancer Registrars Association

For a list of accredited training programs, visit

Commission on Accreditation for Health Informatics and Information Management Education

O*NET

Medical Records and Health Information Technicians

Suggested citation:

Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Medical Records and Health Information Technicians,
on the Internet at https://www.bls.gov/ooh/healthcare/medical-records-and-health-information-technicians.htm (visited ).

 

Tracey Lamphere

Tracey Lamphere, M.S. IMC is the editor of Job Affirmations, a publication that provides information and ideas to use mindfulness, positive affirmations, and visualizations to transform your career.

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