What is a Medical Records Technician?

A medical records technician, also known as a health information technician or medical coder, is a skilled administrative professional responsible for compiling, organizing, and managing patient health information in medical records systems. Medical records technicians ensure the completeness, accuracy, confidentiality, and accessibility of medical records, facilitating effective communication, continuity of care, and compliance with healthcare regulations and standards.

Medical Records Technician Job Description

We are currently seeking meticulous and detail-oriented medical records technicians to join our healthcare team and ensure the accurate and efficient management of patient health information. As essential members of our administrative staff, successful candidates will play a vital role in organizing, maintaining, and safeguarding medical records to support quality patient care and regulatory compliance.

As a medical records technician, you will have the opportunity to process, analyze, code, and classify medical data, including diagnoses, procedures, treatments, and outcomes, to support billing, reimbursement, research, and healthcare delivery processes.

The ideal candidates will possess strong organizational skills, attention to detail, and knowledge of medical terminology, coding systems, and health information management principles.

What Does a Medical Records Technician Do?

• Manage Health Information: Compile, organize, and maintain paper-based and electronic medical records, including patient demographic information, medical histories, diagnostic test results, treatment plans, progress notes, and other clinical documentation, using electronic health record (EHR) systems and health information management (HIM) software applications.
• Review, verify, and update patient health information for accuracy, completeness, and compliance with regulatory requirements, organizational policies, and accreditation standards, ensuring data integrity, confidentiality, and security in medical records systems.
• Assign Diagnostic and Procedural Codes: Abstract, code, and classify medical diagnoses, procedures, treatments, and services using standard coding systems, such as International Classification of Diseases (ICD), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and Diagnosis-Related Groups (DRG), to support billing, reimbursement, and healthcare analytics.
• Ensure Coding Accuracy: Analyze medical records, clinical documentation, and physician notes to accurately assign diagnostic and procedural codes based on established coding guidelines, coding conventions, and documentation requirements, resolving discrepancies and seeking clarification from healthcare providers as needed to ensure coding accuracy and compliance.
• Facilitate Information Exchange: Retrieve and disseminate patient health information to authorized healthcare providers, insurance companies, government agencies, and other stakeholders in accordance with privacy regulations, confidentiality policies, and release of information (ROI) protocols, promoting effective communication, care coordination, and continuity of care.
• Support Quality Improvement: Participate in quality assurance (QA) and quality improvement (QI) initiatives, medical record audits, and compliance reviews to identify coding errors, documentation deficiencies, and data inaccuracies, collaborating with interdisciplinary teams to implement corrective actions, training programs, and best practices to enhance data quality and integrity.
• Provide Customer Service: Assist patients, healthcare providers, and other stakeholders with inquiries, requests, and concerns related to medical records, health information access, and record retrieval processes, providing courteous, timely, and accurate assistance to ensure customer satisfaction and service excellence.
• Maintain Compliance: Adhere to federal, state, and local regulations governing health information privacy, security, and confidentiality, including Health Insurance Portability and Accountability Act (HIPAA) regulations, Electronic Health Record (EHR) meaningful use criteria, and Health Information Exchange (HIE) standards, to protect patient rights and safeguard sensitive health information.

How Much Do Medical Records Technicians Make?

Medical Records Technicians made a median salary of $47,180 in 2022. The best-paid 25% made $60,170 that year, while the lowest-paid 25% made $37,510.

Skill Requirements

• Organizational Skills: Medical records technicians must possess strong organizational skills and attention to detail in managing medical records, including filing, indexing, and retrieving documents, to ensure accuracy, completeness, and accessibility of patient health information.
• Medical Terminology: Medical records technicians should have a solid understanding of medical terminology, anatomy, physiology, and disease processes to interpret and accurately code clinical diagnoses, procedures, treatments, and services in medical records.
• Health Information Management: Medical records technicians must be familiar with health information management (HIM) principles, standards, and practices, including electronic health records (EHR), health data management, confidentiality, privacy, security, and release of information (ROI), to ensure compliance with regulatory requirements and organizational policies.
• Coding Systems: Medical records technicians should be proficient in coding systems, such as International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS), and coding guidelines to accurately assign diagnostic and procedural codes in medical records.
• Electronic Health Records (EHR): Medical records technicians should have experience working with electronic health record (EHR) systems and health information technology (HIT) applications to input, retrieve, and manage electronic medical records efficiently and securely.
• Attention to Detail: Medical records technicians must demonstrate attention to detail in reviewing, analyzing, and verifying medical records and coding documentation to ensure accuracy, consistency, and compliance with coding guidelines and regulatory requirements.
• Analytical Skills: Medical records technicians should possess strong analytical skills to interpret and abstract complex medical data from clinical documentation, identify coding discrepancies, and resolve coding-related issues effectively to support accurate billing, reimbursement, and healthcare analytics.

Example KPIs for a Medical Records Technician

• Coding Accuracy and Compliance: This KPI measures medical records technicians’ accuracy and compliance in assigning diagnostic and procedural codes, ensuring adherence to coding guidelines, conventions, and regulatory requirements, as evidenced by coding audits, error rates, and compliance reports.
• Data Integrity and Quality: This KPI evaluates medical records technicians’ effectiveness in maintaining data integrity and quality in medical records systems, including completeness, accuracy, and timeliness of data entry, coding, and documentation, as demonstrated by data validation, error rates, and QA/QI metrics.
• Workflow Efficiency and Productivity: This KPI assesses medical records technicians’ efficiency and productivity in managing medical records, coding tasks, and information requests, optimizing workflow processes, turnaround times, and resource utilization, as measured by productivity metrics and performance benchmarks.
• Customer Service and Satisfaction: This KPI measures medical records technicians’ customer service skills and satisfaction levels in responding to inquiries, requests, and concerns from patients, healthcare providers, and other stakeholders, as evaluated by customer feedback, surveys, and service ratings.
• Professional Development and Training: This KPI evaluates medical records technicians’ engagement in ongoing professional development, continuing education, and training activities to enhance coding skills, expand clinical knowledge, and stay abreast of changes in coding regulations and technology.

How Can Glider AI Help You with Hiring a Medical Records Technician?

Glider’s recruitment platform is designed to prioritize competency over credentials, enabling organizations to assess candidates’ skills objectively and efficiently. Utilize Glider AI Skill Intelligence™ to streamline the hiring process, identify top-quality Medical Records Technician candidates, and ensure a mobile-first, candidate-friendly experience.

Glider AI’s Unique Features

• Verify Medical Licenses
• Validate Hundreds of Medical, Clinical, and Technical Skills
• Ensure Hiring Compliance
• Conversational Chatbot for Talent Screening
• Powerful candidate analytics
• Streamline Healthcare Hiring with AI and Automation

Go ahead and spotlight your Medical Records Technician with Glider AI today!

Schedule a Demo or contact us at info@glider.ai