Clinical Review Specialist (Remote)

Site: Mass General Brigham Incorporated

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 patient’s 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
• Bachelor’s degree healthcare related preferred
• Strong PC skills / Microsoft applications, including Outlook, Teams, Excel, PowerPoint

Additional Job Details (if applicable)

Remote Type

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range

$62,400.00 - $90,750.40/Annual

Grade

6

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

EEO Statement:

Mass General Brigham Incorporated is an Equal Opportunity Employer. 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 law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

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.