PHM Clinical Review Specialist
Apply NowCompany: Mass General Brigham
Location: Somerville, MA 02145
Description:
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:
Drive Clinical Delivery
Performs accurate and timely pre-visit 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 diagnose
Presents clear HCC Consideration Communication to provider and educates providers to obtain greatest possible diagnostic specificity to accurately reflect the patient's condition(s)
Identify Education Opportunitie
Identifies themes through chart review that might present education opportunities for individual or groups of provider
Gathers feedback from periodic post-visit chart reviews and incorporates these learnings into educational opportunities with provider
Identifies opportunity for Process Improvement and Quality Improvement, as needed
Foster collaborative relationships across the enterprise
Communicates appropriately and compliantly with physician or care team through Epic resources 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. Reviews professional CDI and coding literature regularly
Maintains clinical licensure (e.g. RN, PA, NP) to practice in the Commonwealth of MA and completes all required Organizational Competencies and training
Meets with providers on an as-needed basis to address concerns or areas of opportunity, and performs chart reviews as needed
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
Qualifications
Qualifications:
Bachelors' Degree in Nursing, Physician Assistant or other clinical healthcare related field required
Minimum three (3) - five (5) years' experience required in either clinical nursing, case management, Outpatient Coding, Utilization Review, Physician Assistant or other clinical disciplines with either coding or CDI experience however, an equivalent combination of education and experience, which provides proficiency in the areas of responsibility, may be substituted for the stated education and experience requirements.
Current licensure in the state of employment as an RN, NP, PA, or licensure in the specific medical field associated with a Doctorate degree required
2 years' experience in Primary Care, medical coding, risk adjustment or CDI preferred
Current certification in Clinical Documentation Improvement (CDIP, CCDS, CCDS-O or CDEO) highly preferred or appropriate certification within 2 years of employment
Certification in medical coding and or risk adjustment (i.e., CRC, CPC, CCS, or CCS-P or other pertinent to outpatient) preferred
Strong PC skills / Microsoft applications, including Excel, Access, Project, PowerPoint
Skills, Abilities and Competencies:
Skills for Succe
Working knowledge of the Medicare Advantage reimbursement system, Risk-based Contracts and HCC Coding
Superior analytic and problem-solving skills with a high value in data integrity and analytic accuracy
Ability to conduct detailed analysis as well as distill relevant findings for presentation to a high-level audience
Creativity and enthusiasm for developing and implementing new program
Team Player
An inclusive individual who thrives in a highly matrixed, collaborative, team-oriented environment
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
A hybrid work model, with two days per month onsite at Assembly Row for PHM meeting
EEO Statement
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.
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:
Drive Clinical Delivery
Performs accurate and timely pre-visit 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 diagnose
Presents clear HCC Consideration Communication to provider and educates providers to obtain greatest possible diagnostic specificity to accurately reflect the patient's condition(s)
Identify Education Opportunitie
Identifies themes through chart review that might present education opportunities for individual or groups of provider
Gathers feedback from periodic post-visit chart reviews and incorporates these learnings into educational opportunities with provider
Identifies opportunity for Process Improvement and Quality Improvement, as needed
Foster collaborative relationships across the enterprise
Communicates appropriately and compliantly with physician or care team through Epic resources 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. Reviews professional CDI and coding literature regularly
Maintains clinical licensure (e.g. RN, PA, NP) to practice in the Commonwealth of MA and completes all required Organizational Competencies and training
Meets with providers on an as-needed basis to address concerns or areas of opportunity, and performs chart reviews as needed
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
Qualifications
Qualifications:
Bachelors' Degree in Nursing, Physician Assistant or other clinical healthcare related field required
Minimum three (3) - five (5) years' experience required in either clinical nursing, case management, Outpatient Coding, Utilization Review, Physician Assistant or other clinical disciplines with either coding or CDI experience however, an equivalent combination of education and experience, which provides proficiency in the areas of responsibility, may be substituted for the stated education and experience requirements.
Current licensure in the state of employment as an RN, NP, PA, or licensure in the specific medical field associated with a Doctorate degree required
2 years' experience in Primary Care, medical coding, risk adjustment or CDI preferred
Current certification in Clinical Documentation Improvement (CDIP, CCDS, CCDS-O or CDEO) highly preferred or appropriate certification within 2 years of employment
Certification in medical coding and or risk adjustment (i.e., CRC, CPC, CCS, or CCS-P or other pertinent to outpatient) preferred
Strong PC skills / Microsoft applications, including Excel, Access, Project, PowerPoint
Skills, Abilities and Competencies:
Skills for Succe
Working knowledge of the Medicare Advantage reimbursement system, Risk-based Contracts and HCC Coding
Superior analytic and problem-solving skills with a high value in data integrity and analytic accuracy
Ability to conduct detailed analysis as well as distill relevant findings for presentation to a high-level audience
Creativity and enthusiasm for developing and implementing new program
Team Player
An inclusive individual who thrives in a highly matrixed, collaborative, team-oriented environment
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
A hybrid work model, with two days per month onsite at Assembly Row for PHM meeting
EEO Statement
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.