Compliance & Records Specialist

JOB PURPOSE : Ensure medical records are accurate, compliant, and complete to support successful claims and minimize denials. Manage record reviews, audits, and appeals while collaborating with internal teams and BPO counterparts to maintain updated guidelines and drive process improvements.

Job Duties and Responsibilities

• Ensure accurate record reviews, retrieve medical records, and send out medical record requests as needed within the required time frame.
• Ensure medical records are compliant with payer-specific guidelines before submission.
• Investigate medical record denials, and communicate actions that need to be taken to resolve them and document findings on CMD and the Jira Project.
• Initiate appeals to the payer as necessary to resolve medical record denials.
• Thoroughly navigate and manage post-payment and pre-payment reviews, ensuring proper documentation, timely responses, and compliance with regulatory and contractual requirements.
• Research and update payer-related guidelines regularly, ensuring all departments follow best practices and have access to the most current documentation.
• Support training and day-to-day guidance for BPO team members by sharing knowledge, addressing questions, and escalating needs or issues to the lead or supervisor to strengthen performance and ensure aligned, efficient operations.
• Participate in the department's L10 meetings, identify and bring issues, and develop and execute quarterly rocks to drive alignment and improvements toward Cipher VTO.
• Ensure clear and efficient communication by responding to partner emails and requests promptly.
• Perform facility spot checks to maintain charts / documentation up to date with payer guidelines.
• Perform other related duties as assigned.

Minimum Qualifications

Education / Experience