Sr. Specialist, RADV Retrieval

Hingham

Full time

R08951

Ready to help us transform healthcare? Bring your true colors to blue.

The Role

The Senior Specialist, RADV Retrieval is responsible for executing the day-to-day medical record retrieval operations supporting internal risk adjustment (RA) audits, CMS-RADV, HHS-RADV, and other regulatory audit activities. This role focuses on obtaining complete medical records for internal and external Medicare Advantage (MA) and Affordable Care Act (ACA) audit samples to ensure high-yield, compliant, and timely acquisition within strict regulatory windows.

Working collaboratively with the Lead Specialist, the Senior Specialist conducts direct outreach to provider offices, Health Information Management (HIM) departments, and contract retrieval vendors to resolve operational barriers, track chart progress, and maintain audit defensibility.

Key Responsibilities

Core Retrieval Execution & Provider Outreach

• Execute end-to-end medical record retrieval activities across internal audit, MA CMS-RADV, and ACA HHS-RADV audit samples, managing competing deadlines across overlapping audit cycles.

• Conduct direct provider, clinic, and HIM department outreach to request records, clarify documentation needs, and resolve retrieval bottlenecks.

• Manage outreach cadence and professional communication to minimize provider abrasion and preserve positive provider network relationships.

• Maintain detailed, time-stamped documentation of all outreach attempts, contact methods, escalations, and receipt confirmations to ensure full audit defensibility.

Vendor & Workflow Coordination

• Coordinate daily medical record retrieval workflows with external retrieval and coding vendors to track sample completion against established targets.

• Perform primary source verification on retrieved records to ensure completeness, legibility, and compliance prior to coding handoff.

• Partner with internal coding, quality assurance, and data analytics colleagues to route retrieved charts and prioritize urgent, high-risk, or time-sensitive samples.

• Escalate persistent provider non-response, system barriers, or timeline risks promptly to the Lead Specialist and Senior Manager.

Compliance & Process Support

• Ensure all chart acquisition and data transfer activities strictly adhere to HIPAA, HITECH, CMS, HHS, and organizational secure PHI transmission protocols.

• Maintain accurate, real-time tracking of assigned audit sample retrieval status, yields, and turnaround times in tracking systems.

• Participate in recurring quality checks to ensure retrieved documentation meets regulatory audit submission standards.

• Support special projects and process improvement initiatives within the RADV Compliance Center of Excellence.

Qualifications

Education

• High school diploma or GED required OR a minimum of three (3) years of relevant healthcare/HIM experience in lieu of a degree.

Experience & Skills

• Minimum two (2) to four (4) years of experience in medical record retrieval, provider outreach, health information management (HIM), or risk adjustment operations.

• Working knowledge of MA and ACA risk adjustment models, CMS-RADV / HHS-RADV audit timelines, and medical documentation standards.

• Demonstrated experience coordinating retrieval workflows across multiple providers, clinics, and third-party vendors simultaneously.

• Working knowledge of HIPAA, HITECH, and secure electronic PHI transmission protocols.

• Strong organizational and time-management skills with proven ability to handle high-volume, deadline-sensitive caseloads.

• Effective interpersonal, verbal, and written communication skills.

Preferred Qualifications

• Associate degree in Health Information Technology, Healthcare Administration, or related field.

• Certified Medical Records Technician (CMRT), Registered Health Information Technician (RHIT), or equivalent HIM credential.

Minimum Education Requirements:

High school degree or equivalent required unless otherwise noted above

LocationHinghamTime TypeFull time

Hourly Range: $31.91 - $37.06

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that the confidence gap (https://www.theatlantic.com/magazine/archive/2014/05/the-confidence-gap/359815/) and imposter syndrome (https://www.braintreepayments.com/blog/overcoming-imposter-syndrome/) can prevent amazing candidates coming our way, so please don’t hesitate to apply. We’d love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It’s in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture (https://careers.bluecrossma.org/us/en/culturepage) page. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join our Talent Community (https://careers.bluecrossma.org/us/en/jointalentcommunity?applyType=JTC) to stay “in the know” on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work (https://careers.bluecrossma.org/us/en/how-we-work) " Page.

Voted as the highest in member satisfaction among Massachusetts commercial health plans by JD Power , Blue Cross Blue Shield of Massachusetts is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. We have been a market leader for over 75 years, and are consistently ranked among the nation's best health plans. Our daily efforts are dedicated to effectively serving our 2.8 million members, and consistently offering security, stability, and peace of mind to both our members and associates.

Our Commitment to You

We are committed to investing in your development and providing the necessary resources to enable your success. We are dedicated to creating a refreshing and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path. We take pride in our diverse, community-centric, wellness-focused culture and believe every member of our team deserves to enjoy a positive work-life balance.

Blue Cross Blue Shield of Massachusetts is an Equal Employment Employer - veterans/disability. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law.

Blue Cross Blue Shield of Massachusetts will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with Blue Cross Blue Shield of Massachusetts's legal duty to furnish information.