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Part-time Project Based Consultant Risk Adjustment Clinical Reviewer

Position Summary

The RADV Clinical Reviewer is responsible for conducting clinical reviews of medical records to validate the accuracy and completeness of diagnosis coding submitted for Medicare Advantage risk adjustment. This role supports Risk Adjustment Data Validation (RADV) audits, and retrospective chart reviews by ensuring documentation accurately supports reported conditions.

Key Responsibilities

• Review medical records to validate diagnoses submitted for risk adjustment and RADV audits.
• Evaluate clinical documentation to determine whether reported HCCs are supported according to CMS guidelines.
• Collaborate with coding, compliance, provider education, and audit teams to resolve documentation issues.
• Interpret CMS regulations, RADV protocols, and risk adjustment requirements.
• Participate in internal mock audits, quality assurance reviews, and audit preparedness activities.
• Conduct provider documentation assessments and contribute to educational feedback.
• Maintain accurate audit findings, review determinations, and supporting documentation.
• Assist with root cause analysis of validation failures and support corrective action plans.
• Meet productivity, quality, and turnaround time expectations.

Qualifications

Required

• Active, unrestricted RN, clinical license.
• Minimum of 3-5 years of clinical experience.
• Experience reviewing medical records and interpreting clinical documentation.
• Strong knowledge of disease processes, treatment standards, and clinical documentation requirements.
• Proficiency with electronic medical records and audit tools.
• Strong analytical and written communication skills.

Preferred

• Experience with Medicare Advantage risk adjustment.
• Knowledge of CMS RADV audit methodology.
• Certified Risk Adjustment Coder (CRC) certification.
• Certified Professional Coder (CPC), CCS, or other coding certification.
• Experience supporting health plan, provider group, or consulting organization risk adjustment programs.
• Familiarity with HCC model methodology and ICD-10-CM coding guidelines.

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