PreVisit 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. 

General Overview

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 diagnoses
• 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 Opportunities
• Identifies themes through chart review that might present education opportunites 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

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 (. RN, PA, NP) to practice in the Commonwealth of MA and completes all required Organizational Competencies and trainings
• Meets with providers on an as-needed basis to address concerns orareas of opportunity, and performs chart reviews as needed 
• Maintains good rapport and professionalrelationships, 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

• Bachelors’ Degree in Nursing, Physician Assistant or other clinical heathcare 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 (., 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 Success
• 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 programs

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

• A hybrid work model, with two days per month onsite at Assembly Row for PHM meetings.