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PHM Clinical Review Specialist at Partners Healthcare System

PHM Clinical Review Specialist

Partners Healthcare System Somerville, MA (Onsite) Full-Time
About Us:

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 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 Senior Program Manager, 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 clinical documentation, and disease registry assignments. The CRS RN 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.


Perform Clinical Chart Review

Performs accurate and timely pre-visit chart 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 with relevant supporting clinical indicators regarding diagnostic specificity in context of compliance considerations

Perform audit as part of ongoing quality assurance program as assigned

Identify and Provide 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

Collaborate on and contribute to educational materials for provider training

Clinical Oversight

Be available to coders for clinical issues that arise (no direct report)

Meet on a regular basis with clinical leadership to escalate any ongoing clinical issues from the coders or themselves

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 trainings

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


Primarily a remote work model. Periodic on-site meetings as assigned.

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Normal office working conditions. The noise level in the work environment is quiet to moderate.

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 Commonwealth of Massachusetts 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

Certification in medical coding and or risk adjustment (i.e., CRC, CPC, CCS, or CCS-P or other pertinent to outpatient) preferred or CRC certification within first year of employment

Strong PC skills / Microsoft applications, including Excel, Access, Project, PowerPoint


Skills for Success

Working knowledge of the Medicare Advantage reimbursement system, Risk-based Contracts, HCC Coding, and healthcare compliance

Superior analytic and problem-solving skills with a high value in data integrity and analytic accuracy

Ability to understand detailed analysis as well as be able to discuss findings with other members of the team

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


No direct reports; may indirectly provide leadership and guidance to less seasoned and new staff


No direct budgetary responsibility

Demonstrates fiscal responsibility by effectively using Mass General Brigham resources

Diversity Statement

As a not-for-profit organization, Mass General Brigham is committed to supporting patient care, research, teaching, and service to the community. We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve. At Mass General Brigham, we believe in equal access to quality care, employment and advancement opportunities encompassing the full spectrum of human diversity: race, gender, sexual orientation, ability, religion, ethnicity, national origin and all the other forms of human presence and expression that make us better able to provide innovative and cutting-edge healthcare and research.

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