[Hiring] Medical Retrieval and Risk Adjustment Consultant @MedCap Health

Role Description

To obtain, manage, and upload medical records to health plan/payor portals in support of risk adjustment audits, HEDIS audits, RADV reviews, and related compliance activities.

Scope of Responsibilities

• Medical Record Retrieval
  • Collaborate with internal stakeholders to obtain access and retrieval of medical records as requested by payors.
  • Contact external facilities to request medical records when documentation is not internally available.
  • Track and manage assigned retrieval projects to ensure records are obtained within established deadlines.
  • Verify that records received correspond to the correct member, date of service, and audit.
  • Escalate barriers to retrieval, including provider refusals, incomplete records, or missed deadlines with the Chief Compliance Officer.
• Records Management
  • Organize records in accordance with company naming conventions and document retention requirements.
  • Review records for legibility and completeness prior to submission.
  • Separate duplicate, incomplete, or irrelevant documentation and communicate deficiencies to the designated project lead.
  • Maintain accurate tracking logs reflecting retrieval status, submission dates, and outstanding actions.
• Payor Portal Submission
  • Upload medical records and supporting documentation to payor, health plan, or auditor portals.
  • Ensure accurate member matching and record indexing prior to submission.
  • Verify successful uploads and maintain proof of submission when available.
  • Resolve portal-related issues, including rejected files, upload errors, and missing documentation notifications.
• Compliance and Confidentiality
  • Maintain strict confidentiality of Protected Health Information (PHI) and Personally Identifiable Information (PII).
  • Comply with all applicable federal and state privacy requirements, including HIPAA and HITECH regulations.
  • Access only the minimum necessary information required to perform assigned duties.
  • Immediately report any suspected privacy, security, or compliance incidents.
  • Use only approved systems, devices, and transmission methods for handling PHI.
• Communication and Reporting
  • Provide regular status updates regarding assigned retrieval activities.
  • Respond to communications from company representatives within established timeframes.
  • Participate in project meetings or training sessions as requested.
  • Notify management promptly of any anticipated delays affecting project completion.

Qualifications

• Ability to pass a background check.

Requirements

• Complete assigned retrieval and upload activities by established project deadlines.
• Maintain active management of all assigned provider outreach and follow-up activities.
• Perform timely data entry and status updates in designated tracking systems.
• Achieve a minimum 98% accuracy rate for record indexing, member identification, and portal uploads.
• Ensure records submitted are complete, legible, and aligned with audit requirements.
• Verify successful submission prior to closing assignments.
• Acknowledge newly assigned work within one business day.
• Initiate provider outreach within two business days of assignment.
• Complete uploads within required audit submission deadlines.
• Respond to contractor management inquiries within one business day.
• Complete all required HIPAA, privacy, and security training before accessing PHI.
• Adhere to all company compliance policies and payor requirements.
• Maintain zero tolerance for unauthorized disclosure of PHI or confidential information.
• Conduct all interactions with provider offices and stakeholders professionally and respectfully.
• Maintain accurate and truthful documentation of retrieval and upload activities.
• Demonstrate reliability, accountability, and attention to detail.

Deliverables

• Accurate retrieval status tracking for all assigned records.
• Complete and timely medical record submissions to designated payor portals.
• Documentation of provider outreach and follow-up activities.
• Confirmation of successful record uploads and audit submissions.
• Timely escalation of issues that may affect audit completion or compliance requirements.
• Failure to meet quality, compliance, confidentiality, or deadline requirements may result in reassignment or termination of the independent contractor engagement.