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 is charged with the challenge to drive better value for patients across Mass General Brigham. PHM leverages financial and clinical data to examine opportunities, designs, and delivers innovative care models, and leverages problem-solving, teamwork, and leadership skills to drive ongoing improvements.
The Medicare Advantage Engagement Team RN, Population Health Management (MA Engagement Team RN) 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 MA Engagement Team 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. The MA Engagement Team RN nurtures strong relationships with physicians, nursing staff, other patient care providers, and the Population Health Coordinators to promote appropriate clinical documentation through collaborative communication.Duties and Responsibilities: Coding Review Responsibilities
- Reviews patient records and compares with visit diagnoses looking for chronic conditions that are present but have not been captured by ICD-10 code in the billing system (suspect conditions).
- Compares diagnoses on the patients' problem lists to current year billing records to determine which conditions, if any, haven't yet been captured (gap conditions).
- Reviews charts with suspect and gap conditions to ensure that appropriate documentation exists to support coding for those conditions following documentation and compliance policies.
Identify Education Opportunities
- Alerts provider of identified potential diagnoses via a reminder in EPIC/EMR prior to a patient visit.
- Conducts post- visit audits to assess if clinician captured these diagnoses with appropriate documentation and visit diagnosis.
- Updates patient's problem list as clinically appropriate based upon review of prior documentation or relevant test results.
- Educates and trains providers on how to utilize available tools to improve their knowledge and coding skills while staying within the guidelines.
Foster collaborative relationships across the enterprise
- 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.
- Communicates appropriately and compliantly with physician or care team through Epic resources to improve medical record documentation.
- 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) 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 professional relationships, as outlined in MGB Code of Conduct.
- Approaches conflict in a constructive manner, helps identify problems, offer solutions and participate in resolution.
- Bachelor's degree in nursing, required.
- Minimum three (3) - five (5) years' experience required in either clinical nursing, case management, outpatient coding, utilization review or other clinical disciplines with either coding or CDI experience.
- 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.
- Board certified Registered Nurse with licensure in good standing in the Commonwealth of Massachusetts.
- 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 (i.e., CRC, CPC, CCS, or CCS-P or other pertinent to outpatient) preferred.
- Strong PC skills / Microsoft applications, including Excel, Access, Project, PowerPoint
- Excellent knowledge of HCCs and diagnostic criteria.
- Strong written and verbal communication skills.
- Strong analytical, organizational and time management skills.
- Strong knowledge of Microsoft Office.
- Prior experience and knowledge of Electronic Health Records.
- 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.
- 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.
- Hybrid work environment, office-based work as well as remote work.
Mass General Brigham 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.