Clinical Review Specialist

As a not-for-profit organization, Mass General Brigham is committed to supporting patient care, research, teaching, and service to the community by leading innovation across our system. Founded by Brigham and Women's Hospital and Massachusetts General Hospital, Mass General Brigham supports a complete continuum of care including community and specialty hospitals, a managed care organization, a physician network, community health centers, home care, and other health-related entities. Several of our hospitals are teaching affiliates of Harvard Medical School, and our system is a national leader in biomedical research.

We're focused on a people-first culture for our system's patients and our professional family. That's why we provide our employees with more ways to achieve their potential. Mass General Brigham is committed to aligning our employees' personal aspirations with projects that match their capabilities and creating a culture that empowers our managers to become trusted mentors. We support each member of our team to own their personal development-and we recognize success at every step.

Our employees use the Mass General Brigham values to govern decisions, actions, and behaviors. These values guide how we get our work done: Patients, Affordability, Accountability & Service Commitment, Decisiveness, Innovation & Thoughtful Risk; and how we treat each other: Diversity & Inclusion, Integrity & Respect, Learning, Continuous Improvement & Personal Growth, Teamwork & Collaboration.

The Opportunity:

The Population Health Management (PHM) department at Mass General Brigham aims to deliver health and healthcare for all by translating the evolving needs of the healthcare landscape into innovative solutions to better serve individuals, communities, and organizations.

In the healthcare industry, we are in a time like no other. Experts estimate that healthcare will evolve more in the next few years than it has in the last 50 years. We have seen governments, employers, and families struggle in the face of rising healthcare costs and a fragmented healthcare system. Patients and communities need more convenient, more affordable, and higher quality care.

We are building a team that can reimagine healthcare and design care models that meet the needs of the people we serve. We are bringing a fresh perspective and a unique approach to create impact for the greater good. By bringing together people from various disciplines and ideas from different industries, we're seeking to address the complex challenges within our healthcare system and leaning forward into a new era of healthcare.

Under the general direction of the Director of Risk Capture, the Pre-Visit Clinical Review Specialist (CRS) facilitates the accurate and appropriate identification of patient medical conditions through comprehensive chart review combined with review of coding output data sources (internal and external claims) that results in improvement in the overall quality, completeness and accuracy of problem lists, visit documentation and disease registry assignments. The CRS utilizes both clinical and coding knowledge of Hierarchical Condition Categories (HCCs) to inform accurate and appropriate diagnosis considerations for suspect condition identification and recapture opportunities. This role serves to educate providers and the clinical care team on all aspects of risk capture and linkages with quality.

Principal Duties and Responsibilities:

Perform Clinical Chart Review

* Performs accurate and timely pre-visit chart review of selected ambulatory encounters to identify opportunities to recapture medical conditions that meet criteria as HCC diagnoses and to capture new, suspected HCC conditions

* Accurately interprets clinical information in the medical record, evaluating clinical indicators to identify potential diagnoses

* Presents clear HCC Consideration Communication to provider with relevant supporting clinical indicators regarding diagnostic specificity in context of compliance considerations

* Perform audit as part of ongoing quality assurance program as assigned

Identify and Provide Education Opportunities

* Identifies themes through chart review that might present education opportunities for individual or groups of providers

* Gathers feedback from periodic post-visit chart reviews and incorporates these learnings into educational opportunities with providers

* Identifies opportunity for Process Improvement and Quality Improvement, as needed

* Collaborate on and contribute to educational materials for provider training

Clinical Oversight

* Meet on a regular basis with clinical leadership to escalate any ongoing clinical issues from the coders or themselves

Foster collaborative relationships across the enterprise

* Maintains clinical licensure (e.g. RN, PA, NP) and/or coding credentials (e.g., CRC, CCS, CPC) to practice in the Commonwealth of MA and completes all required Organizational Competencies and trainings

* Communicates appropriately and compliantly with physician or care team via Epic Best Practice Advisory to improve medical record documentation

* Participates in ambulatory unit/organizational programs and meetings as needed

* Maintains professional competency by keeping abreast of new coding issues and guidelines. Attends classes and meetings as assigned

* Maintains good rapport and professional relationships, as outlined in MGB Code of Conduct

* Approaches conflict in a constructive manner, helps identify problems, offer solutions and participate in resolution

Responsible to perform any and all other assigned duties as requested

WORKING CONDITIONS:

* Primarily a remote work model. Periodic on-site meetings as assigned.

* The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Normal office working conditions. The noise level in the work environment is quiet to moderate.

Qualifications:

* Bachelors' Degree in Nursing, Physician Assistant or other healthcare related field required

* Minimum three (3) - five (5) years' experience required in either clinical nursing, case management, Outpatient Coding, Utilization Review, CDI, or other clinical disciplines

* Current licensure in the Commonwealth of Massachusetts as an RN, NP, PA, or licensure in the specific medical field associated with a Doctorate degree AND/OR certification in medical coding and or risk adjustment (CRC, CPC, CCS, or CCS-P) required

o RN, NP, PA licensure may be from any U.S. state

* Experience in risk adjustment and/or risk adjustment coding preferred

* Strong PC skills / Microsoft applications, including Excel, Outlook, Teams, PowerPoint etc.

SKILLS/ABILITIES/COMPETENCIES:

Skills for Success

* Working knowledge of Risk-based Contracts, HCC Coding, and healthcare compliance

* Strong critical thinking and problem solving skills

* Creativity and enthusiasm for developing and implementing new processes/workflows

Team Player

* An inclusive individual who thrives in a highly matrixed, collaborative, team-oriented environments

* Strong interpersonal and team building skills. Ability to get work done through others, even if there is no direct reporting relationship

* Ability to successfully collaborate with others of different skill sets, backgrounds, and levels within and external to the organization

Commitment to Quality

* Accountable for delivering high quality work. Act with a clear sense of ownership

Mass General Brigham is an Equal Opportunity Employer. By embracing diverse skills, perspectives, and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under the law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, perform essential job functions, and receive other benefits and privileges of employment.