Accurate medical records are critical to effective health care delivery and the Medical Records Specialists who handle them have a lot of responsibility. To perform the tasks of the job, you need technical skills that include computer savvy and knowledge of medical terminology and the codes these medical translators use every day. You also need to know how to follow rules on confidentiality and information security to keep important data safe. Take a closer look at the technical skills you need to become a medical records specialist:
Medical Terminology
Medical professionals speak their own technical language and if you want to work in healthcare, you need to be nearly fluent. You need to know the medical terminology for different structures and functions of the human body along with the correct terms for common diseases, diagnoses, and treatments. You need to recognize the words and their abbreviations so you can translate your communication with doctors and nurses into accurate coding information.
Clinical Coding
When patients visit the doctor for a routine exam, a follow-up appointment, or a medical procedure, you enter that information into their medical record. And each diagnosis, treatment, and procedure has its own code. The ICD-10 is an industry manual that you can use to look up these codes, but you’ll want to have the most commonly used codes memorized. This skill is essential for both medical records management and for insurance billing.
Medical Insurance Billing
Once a patient’s record is accurately coded, you can use those codes to fill out insurance claims. The insurance company will use those same codes to determine if the patient’s plan covers their treatment and how much they should reimburse your facility. As a Medical Records Specialist, you need to be skilled in the billing process. This includes knowledge of insurance forms, super bills and invoices, and billing software.
HIPAA Rules and Regulations
The Health Insurance Portability and Accountability Act, better known as HIPAA, is a federal law that’s designed to protect patient information. You need to know its basic components and the rules and regulations that HIPAA requires you to follow. For example, you should know that you can share medical records with a patient’s doctor or medical team, but you can’t disclose their information to third parties such as the media or marketing agencies.
Medical Health Record Systems
One of the most important technical skills you need to develop is the use of medical health record systems. Since medical records are now stored electronically, you need to know how to access them and enter patient information. You should also understand the importance of record retention, accuracy, and security.
Health Record Security
Because electronic records are vulnerable to cyberattacks, HIPAA now provides guidelines for healthcare facilities to help them keep their medical records secure. You should become familiar with their rules for security as well as your facility’s guidelines. It’s important to understand why medical records need to be protected, and how to implement safety measures to keep private information safe.
Do you want to gain the technical skills necessary for a career in healthcare? Charter Career Academy today offers an Electronic Health Records Specialist training program that can prepare you for entry-level work at a medical facility. Our program is affordable, takes up to 17 weeks to complete, and is offered online for flexibility and convenience. Fill out the form to learn more.