Utilization Review Nurse/ Risk Adjustment / HCC Coder

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)

Work Schedule

• Day shift (11:30 am to 8:30 pm PHT)
• Initial 4 months on-site followed by Work from home