New

Clinical Review Specialist

Mass General Brigham (Enterprise Services)
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Jul 12, 2025
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 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 Mass General Brigham Incorporated 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 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.