Clinical Review Specialist
Clinical Review Specialist
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1 Vacancy
Job Description
Mass General Brigham relies on a wide range of professionals including doctors nurses business people tech experts researchers and systems analysts to advance our mission. As a not-for-profit we support patient care research teaching and community service striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.
Job Summary
General Summary: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.
Principle Duties:
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 diagnoses
- Presents clear HCC Consideration Communication to provider and educates providers to obtain greatest possible diagnostic specificity to accurately reflect the patients condition(s)
Identify 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 opportunities 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 and/or medical coding credentials (e.g. RN PA NP CRC CDEO CCS CPC) and completes all required Organizational Competencies and trainings (if applicable)
- 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 offers solutions and participates in resolution
- Responsible to perform any other assigned duties as requested
Qualifications
Minimum three (3) - five (5) years experience required in either case management outpatient coding utilization review CDI or other disciplines with either coding 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.
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) preferred
Certification in medical coding and or risk adjustment (i.e. CRC CPC CCS CDEO or CCS-P or other pertinent to outpatient) preferred (CRC Required training within 1 year of employment)
Medical licensure (RN PA NP) preferred
Bachelors degree healthcare related preferred
Strong PC skills / Microsoft applications including Outlook Teams Excel PowerPoint
Additional Job Details (if applicable)
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
EEO Statement:
Mass General Brigham Competency Framework
At Mass General Brigham our competency framework defines what effective leadership looks like by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance make hiring decisions identify development needs mobilize employees across our system and establish a strong talent pipeline.
Required Experience:
Unclear Seniority
Employment Type
Full-Time
