Job Description

Job Summary:

Prospective clinical reviewers will analyze longitudinal medical records to identify clinically supported suspected conditions that the LLM should learn to surface for prospective provider review. Using clinical judgment, Clinical Documentation Improvement (CDI) principles, TAMPER evidence, and knowledge of chronic disease processes, reviewers will identify potential conditions supported by patterns within the medical record and distinguish meaningful clinical suspects from historical, resolved, unsupported, or otherwise non-actionable findings.

Reviewer output will serve as clinical training and validation data for the LLM, helping improve the model's ability to identify appropriate suspected conditions while minimizing false-positive and clinically unsupported recommendations.

This role does not independently establish a patient diagnosis. Suspected conditions identified through the review process represent potential clinical opportunities for subsequent provider evaluation and confirmation.

Key Responsibilities

The Clinical Reviewer performs a comprehensive review of diagnostic reports, laboratory results, and other relevant medical record documentation to identify clinical indicators that may support potential or suspected HCC/Rx HCC conditions (Prescription Drug Hierarchical Condition Category).
Distinguish active or potentially active conditions from historical, resolved, ruled-out, unsupported, or otherwise non-actionable findings.
Identify potential HCC-related suspects while maintaining appropriate clinical and coding boundaries.
Review and validate LLM-generated suspects as model training and refinement progresses.
Identify false-positive suspects, missed suspects, and clinically unsupported model outputs.
Provide structured clinical reviewer feedback that can be used to improve model performance and suspect-surfacing accuracy.
Participate in clinical calibration to maintain consistency in how suspected conditions and supporting evidence are identified and labeled.
Collaborate with Clinical, Quality, Coding, Product, and LLM training teams as needed to clarify clinical criteria and review expectations.
Escalate ambiguous clinical scenarios, complex cases, and edge cases to Clinical/Quality Leadership.
Meet established accuracy, productivity, and turnaround time expectations for LLM training activities.

Required Qualifications:

Candidates must meet all the following:

· Registered Nurse (RN/USRN) or MBBS graduate.

· Minimum of 3 years of experience in prospective outpatient Clinical Documentation Improvement (CDI), clinical documentation review, medical record review, utilization review, clinical quality, or a related clinical review function

· Working knowledge of clinical documentation requirements and ICD-10-CM diagnosis terminology and principles.

· Experience reviewing outpatient physician documentation and longitudinal medical records.

· Prior exposure to risk adjustment or HCC coding concepts is preferred but not required. Candidates without direct risk adjustment experience must successfully complete project-specific HCC training and competency assessment

· Ability and willingness to complete project-specific training in prospective risk adjustment, HCC concepts, LLM training methodology, and suspect identification

Experience with AI-assisted clinical documentation, abstraction, annotation, model validation, or coding workflows is a plus. (Preferred but not required)
Certification such as CCDS or CDIP (Preferred but not required)