Medical Retrieval and Risk Adjustment Consultant

*1099 Contractor Position

Purpose: 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

The Independent Contractor shall:

1. Medical Record Retrieval
   • Collaborate with internal stakeholder to obtain access and retrieval of medical records as requested by payors. At times this may require contacting external facilities to request medical records (i.e., the 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.
2. 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.
3. 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.
4. 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.
5. 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.

Minimum Performance Expectations

Productivity

• 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.

Quality

• 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.

Timeliness

• 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.

Compliance

• 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.

Professional Conduct

• 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

The Independent Contractor is expected to provide:

1. Accurate retrieval status tracking for all assigned records.
2. Complete and timely medical record submissions to designated payor portals.
3. Documentation of provider outreach and follow-up activities.
4. Confirmation of successful record uploads and audit submissions.
5. 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.

Must have the ability to pass a background check.