Lead Medical Records Technician (HIT)

U.S. Department of Veterans Affairs; Detroit (MI); On-site; USD 62,000 - 80,000; Full time

Benefits offered by this job

Paid Time Off

Federal retirement benefits

Telework: Not Available

Job summary

The U.S. Department of Veterans Affairs' John D Dingell VA Medical Center seeks MRTs HIT to analyze health records, ensure accuracy, timeliness, and completeness in the Electronic Health Record, and support regulatory compliance.

You will perform quantitative and qualitative reviews, abstract data, monitor for documentation standards, and coordinate with clinicians to maintain continuous patient care while meeting Joint Commission, CMS, and VHA guidelines.

Qualifications

• Education or degrees recognized by the U.S. Department of Education must be used for Federal employment.
• Transcripts must be submitted for qualification review and must include detailed information.

Responsibilities

• Serve as technical expert in health record content and documentation requirements.
• Perform quantitative and qualitative reviews of health record documentation.
• Ensure all patient care data in the EHR is accurate, timely, and complete.
• Adhere to documentation requirements outlined by The Joint Commission, VHA guidelines, and medical-legal standards.
• Compile reports to ensure provider-specific and service compliance.
• Lead duties: facilitate team processes and provide guidance to MRT (HIT) staff.

Job description

• Department: Department of Veterans Affairs

This position is located in the Health Information Management (HIM) section at the John D Dingell VA Medical Center. MRTs HIT perform incomplete health record analysis. They review, analyze, abstract, maintain, extract, and compile information from the health record. MRTs HIT check for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance.

Key Responsibilities

Major duties and responsibilities include but are not limited to the following: Serve as technical expert in health record content and documentation requirements. Responsible for performing quantitative and qualitative reviews of health record documentation. Responsible for ensuring that all patient care data entered in Electronic Health Record (EHR) is accurate, timely, and completed.

Adhere to established documentation requirements as outlined by The Joint Commission regulations, Veterans Health Administration (VHA) guidelines, as well as medical‑legal requirements. Review records for adherence with CMS guidelines related to student, resident supervision and attending physician presence and documentation. Compile reports to ensure provider specific and service compliance.

Maintain a control system to ensure completion of all inpatient and outpatient records in accordance with VA, The Joint Commission, CMS and other regulatory agencies standards. Workload Report and contract transcription logs as it relates to timeliness and accuracy of dictated reports completed by medical transcription contractor (as applicable). Review health records for adherence with guidelines related to resident supervision and attending physician presence.

Prepare weekly and monthly reports noting the status of all incomplete/delinquent health records and submits the reports to the appropriate administrative and clinical staff. Participate in routine and focused reviews for the purpose of identifying problems and potential problems in health record documentation as part of the health record review process. Identify and abstract information from health records for special studies and audits both internal and external.

Lead Duties: Facilitates team or unit processes by working in collaboration with team members or employees to ensure that tasks are completed, that good working relationships among team members and with management are maintained, and that team priorities and goals, needs, and achievements are coordinated with management. Performs lead functions over MRT (HIT) positions. Provides guidance and technical direction necessary for accomplishing the work of the unit or team.

Serves as work leader, assuring the work assignments of employees in the unit are carried out. Distributes and balances workload and tasks among employees. Assures the timely accomplishment of work assigned to the team. Assures each team member has an integral role in developing the final product or providing the assigned service.

Communicates to the team the problem to be solved or program issues under review and coaches the team and/or individual team members in identifying the parameters of a viable solution. Ensures the organization's "vision" is integrated into the team's goals, strategies, activity plans, and work products. Ensures team members participate in both short-term and long-term planning stages of team projects.

Continually interacts with team members aimed at building consensus and to serve as negotiator and coach for coordination of team initiatives. Reviews health records to ensure that all records contain sufficient information to meet medical/legal requirements, to ensure continuity of patient care, and to support education and research needs. Assists clinicians with completion of delinquent/incomplete health records. Work Schedule: Monday- Friday; 08:00am- 04:30pm.

Schedule may be subject to change based on the needs of the Agency. Recruitment/Relocation Incentives (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade).

Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience. Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.

Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.

Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Not Available Virtual: This is not a virtual position. Functional Statement #:916080 Permanent Change of Station (PCS): Not authorized

Requirements & Education

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education.

For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/. Transcripts must be submitted if you are basing all or part of your qualifications on education.Transcripts must be official or unofficial college transcripts. A copy of your certificate/degree or screenshot of your current classes are not a replacement of your transcript and they will not be used in the qualifying process.

Transcripts must include the following information: Your Name Name of the college or university Full address of the college or university Degree Received Date Conferred To meet qualification requirements, your resume should clearly identity the following information for each applicable degree: Name of the college or university Degree earned and the field of study Date the degree was conferred (month and year) Please ensure this information is included directly on your resume so your education can be properly evacuated during the qualification review.

Which agency is hiring for this position?

This position is with Veterans Health Administration, Department of Veterans Affairs.

What is the salary for this position?

The posted pay range is $61639 – $80128/yr.

What is the application deadline?

Applications close on 2026-11-16.

Who is eligible to apply?

This position is open under the 'Fed Internal Search' hiring path.