What You'll Do

  • 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.

Career Fit Overview

Use this summary to sense whether the day to day rhythm and focus of this path line up with what energizes you.

Top passions

  • Organizer: Bringing order to data and processes satisfies you.
  • Analyst: Investigating problems and finding patterns keeps you engaged.
  • Helper: Supporting people and making a difference matters to you.

Want a personal read on fit. Take the free assessment and see your exact compatibility with this career and many related roles.

Technologies & Tools

3M Encoder Allscripts EHR Amazing Charts American Medical Association CodeManager Azalea Health Azalea EHR Billing software Coding database software ComChart EMR Computerized indexing systems Corel WordPerfect Office Suite Cyber Records MediChart Express Digital Imaging Communications in Medicine DICOM medical imaging software DRG grouping software e-MDs topsChart eClinicalWorks EHR software EHS CareRevolution Eko Electronic medical record EMR software Electronic medical record EMR systems Email software

How to Become One

This career typically requires vocational school, related on-the-job experience, or an associate's degree. Some specialized training or certification may also be required.

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Also Known As

This career is known by many different job titles across industries. Here are all the variations:

Certified Coding Specialist Certified Medical Coder Certified Professional Coder (CPC) Clinical Documentation Specialist Clinical Office Technician (Clinical Office Tech) Coder Coding Specialist Disability Rater Electronic Health Records Specialist (EHR Specialist) Fee Coder Health Informatics Specialist Health Information Clerk Health Information Coder Health Information Management Hospital Coder (HIM Hospital Coder) Health Information Management Inpatient Coding Auditor (HIM Inpatient Coding Auditor) Health Information Management Technician (HIM Tech) Health Information Specialist Health Information Systems Technician (Health Information Systems Tech) Health Information Technician (Health Information Tech) Health Record Technician (Health Record Tech) Health Records Technician Health Services Information Specialist Inpatient Coder Insurance Coder Medical Administrative Specialist Medical Administrative Technician (Medical Administrative Tech) Medical Bill Coder Medical Biller Medical Biller Coder Medical Billing Coder Medical Billing Specialist Medical Claims Processor Medical Coder Medical Coding Specialist Medical Coding Technician (Medical Coding Tech) Medical Insurance Coder Medical Insurance Coding Specialist Medical Office Technician (Medical Office Tech) Medical Record Assistant Medical Record Coder Medical Record Specialist Medical Records Clerk Medical Records Coordinator Medical Records Custodian Medical Records Specialist Medical Records Technician (Medical Records Tech) Medical Reimbursement Specialist Medical Scribe Outpatient Coder Patient Administration Specialist Registered Health Information Technician (RHIT) Release of Information Specialist ROI Medical Records Specialist (Release of Information Medical Records Specialist)