Medical Retrieval and Risk Adjustment Consultant

MedCap Health•Remote,

8d•Remote

About The Position

Med Cap Health is seeking a Medical Records Retrieval & Payor Audit Specialist to join their growing team. This is a full-time, Monday-Friday 8:00 AM-5:00 PM schedule as a 1099 employee. The role involves working independently with training and support, collaborating with experienced healthcare professionals, and contributing to compliance initiatives and quality patient care outcomes. The company offers competitive pay, medical coverage, dental insurance, paid time off, and 401(k), with a culture focused on flexibility, respect, collaboration, and work-life balance. Med Cap Health emphasizes high-quality, in-house medical care, comprehensive long-term care, and a compassionate, collaborative environment. With over 70 providers across the state, their network is expanding. They provide a flexible and supportive work environment with autonomy and oversight, promoting work-life balance and understanding for unexpected life events.

Requirements

Ability to collaborate effectively with internal stakeholders to secure access to requested medical records
Ability to communicate professionally with external healthcare facilities to obtain records when documentation is not available internally
Strong project management skills with the ability to track and manage retrieval activities while meeting established deadlines
Ability to accurately verify member information, dates of service, and audit requirements
Proven problem-solving skills with the ability to identify and escalate retrieval barriers, including provider refusals, incomplete records, and missed deadlines
Strong organizational skills with the ability to maintain records in accordance with company naming conventions and document retention requirements
Ability to review medical documentation for accuracy, completeness, and legibility prior to submission
Detail-oriented approach to identifying duplicate, incomplete, or irrelevant documentation and communicating deficiencies appropriately
Experience maintaining accurate tracking logs, status reports, and project documentation
Proficiency uploading medical records and supporting documentation to payor, health plan, and auditor portals
Ability to ensure accurate member matching, record indexing, and submission quality
Experience verifying successful submissions and maintaining proof of upload when available
Ability to troubleshoot and resolve upload errors, rejected files, missing documentation notifications, and portal-related issues
Demonstrated commitment to maintaining the confidentiality and security of Protected Health Information (PHI) and Personally Identifiable Information (PII)
Working knowledge of HIPAA, HITECH, and applicable federal and state privacy regulations
Ability to utilize approved systems, devices, and secure transmission methods when handling sensitive information
Strong communication skills with the ability to provide regular project updates and respond promptly to inquiries
Willingness to participate in meetings, training sessions, and ongoing professional development opportunities
Ability to proactively identify and communicate potential delays or issues that may affect project timelines and completion

Responsibilities

Coordinate the retrieval, organization, review, and submission of medical records in support of risk adjustment audits, HEDIS reviews, RADV audits, and related compliance initiatives.
Partner with internal stakeholders and external provider offices to secure required documentation.
Carefully verify records for accuracy and completeness.
Organize files according to established standards.
Ensure timely uploads to designated payor and auditor portals.
Monitor project timelines.
Maintain detailed tracking documentation.
Troubleshoot submission issues.
Protect sensitive information.
Provide ongoing status updates to keep critical healthcare compliance projects moving forward.
Collaborate effectively with internal stakeholders to secure access to requested medical records.
Communicate professionally with external healthcare facilities to obtain records when documentation is not available internally.
Track and manage retrieval activities while meeting established deadlines.
Accurately verify member information, dates of service, and audit requirements.
Identify and escalate retrieval barriers, including provider refusals, incomplete records, and missed deadlines.
Maintain records in accordance with company naming conventions and document retention requirements.
Review medical documentation for accuracy, completeness, and legibility prior to submission.
Identify duplicate, incomplete, or irrelevant documentation and communicate deficiencies appropriately.
Maintain accurate tracking logs, status reports, and project documentation.
Upload medical records and supporting documentation to payor, health plan, and auditor portals.
Ensure accurate member matching, record indexing, and submission quality.
Verify successful submissions and maintain proof of upload when available.
Troubleshoot and resolve upload errors, rejected files, missing documentation notifications, and portal-related issues.
Maintain the confidentiality and security of Protected Health Information (PHI) and Personally Identifiable Information (PII).
Utilize approved systems, devices, and secure transmission methods when handling sensitive information.
Provide regular project updates and respond promptly to inquiries.
Participate in meetings, training sessions, and ongoing professional development opportunities.
Proactively identify and communicate potential delays or issues that may affect project timelines and completion.