Job Description

Solara Specialty Hospitals McAllen is a long-term acute care (LTAC) hospital specializing in the treatment of patients recovering from post-intensive care and medically complex conditions. Our hospital provides both intensive care and telemetry-level services, offering advanced monitoring and support for patients requiring extended medical care. With a multidisciplinary team dedicated to personalized treatment plans, we focus on helping patients achieve significant recovery and transition to the next level of care.

Job Summary

Maintains health information management (HIM) integrity through knowledge of medical record content, medical terminology and abbreviations, abstracting and analysis techniques, concurrent medical record review, terminal-digit filing, medical record storage and retrieval. Demonstrates knowledge of the legal aspects of patient medical records, including release of information and HIPAA Privacy and Security requirements.

Essential Functions

• Demonstrates ability to assemble, analyze, abstract, scan, and maintain medical records appropriately to ensure verifiable documentation.
• Responsible for working with hospital staff, physicians, and administration to ensure that medical records are completed timely, accurately, and completely in a manner that is consistent with hospital policy as well as medical staff bylaws/rules and regulations.
• Responds per HIPAA guidelines to inquiries and requests from physicians, staff, and outside agencies and/or individuals regarding protected health information.
• Demonstrates proficiency with dictation and transcription systems.
• Maintains record indexes and storage and retrieval systems.
• Orders supplies as needed by the department in adequate time to ensure that proper amounts are on hand at all times and that meet budget requirements.
• Demonstrates excellent oral and written communication and interpersonal skills.
• Completes annual health, safety, and education requirements. Maintains professional growth and development.
• Maintains confidentiality of all patient and/or employee information to assure patient and/or employee rights are protected.
• Attends all mandatory in-services and staff meetings.
• Represents the organization in a positive and professional manner.
• Complies with all organizational policies regarding ethical business practices.
• Communicates the mission, ethics, and goals of the hospital, as well as the focus statement of the department.
• Maintains current licensure/certification for position, if applicable.
• Consistently demonstrates Guest Relation’s skills to patients, physicians, visitors, employees, and any other individuals with whom they may come in contact.
• Consistently follows departmental and hospital Health, Safety, Security, Hazardous Materials policies and procedures.

Knowledge/Skills/Abilities

• Ability to investigate and analyze information and to draw conclusions.
• Must read, write and speak fluent English.
• Medical data abstracting skills.
• Ability to foster a cooperative work environment.
• Must have good and regular attendance.
• Approximate percent of time required to travel, 0%
• Performs other related duties as assigned.

Qualifications

Education

• High School Diploma or GED required.
• Associate degree in health information technology preferred, or enrollment in a college/university HIM program accepted.

Licenses/Certification

• Certification as a Registered Health Information Technician (RHIT) by the American Health Information Management Association (AHIMA) preferred.

Experience

• Minimum of 1 year of HIM experience preferred.