**Manager Utilization Management - Remote with Travel in MA

UnitedHealth Group • Boston, MA

402d • Remote

About The Position

The Manager Utilization Management role at UnitedHealth Group involves overseeing and educating a team to ensure quality outcomes in audits and patient care. This position requires collaboration with other managers and the Associate Director, with responsibilities including remote and onsite support, auditing medical records, and ensuring compliance with healthcare regulations. The role emphasizes the importance of diversity and inclusion while aiming to improve health outcomes for the communities served.

Requirements

• Undergraduate degree or 4+ years of equivalent nursing experience.
• Current unrestricted RN nurse license in Massachusetts.
• Active MDS Certification.
• 3+ years of previous Long-Term experience preferred in an Education/Supervisory/Management Role.
• 1+ years of experience and knowledge of MMQ and MDS.
• Knowledge of national clinical practice guidelines (eg. Disease management).
• Knowledge of healthcare insurance industry products (eg. HMO, PPO, ASO).
• Knowledge of Medicaid and Medicare benefit products including applicable state regulations.
• Demonstrated knowledge of applicable area of specialization MMQ/MDS/LTC Regulations.
• Demonstrated knowledge of computer functionality, navigation, and software applications.
• Proven ability to assess, review and apply criteria (eg. Milliman guidelines, CMS criteria, medical policy).
• Proven ability to travel in the state of Massachusetts up to 75% of the time.

Nice To Haves

• Demonstrated knowledge of process flow of UM including clinical appeals and guidance reviews.

Responsibilities

• Supports the team by answering questions and guiding them, leading by example.
• Support the quality outcomes of audits.
• Assist team remotely and onsite with administrative tasks as needed.
• Audit entire medical record for accuracy of the coding on the MMQ/MDS to support accuracy and payment to the nursing facility.
• Utilize technology and support team in EMR programs (PCC, Matrix, EPIC, etc).
• Answer staff questions regarding care (medication, treatment) and benefits.
• Discuss Patient Care specifics with peers or providers in overall patient care and benefits.
• Apply knowledge of pharmacology and clinical treatment protocol to determine appropriateness of care.
• Leverage appropriate clinical terminology when communicating with customers.
• Communicate clinical findings and present rationale for decisions to medical professionals and members at the appropriate level for understanding.
• Work collaboratively with peers/team members and other levels or segments within Optum, UHC.
• Comply with HIPAA guidelines related to Personal Health Information (PHI) when communicating with others.
• Leverage experience and understanding of disease pathology to review chart/clinical information, ask appropriate questions, and identify appropriate course of care in each situation.
• Perform onsite and remote quality review of assessments that includes a review of current and prior patient conditions, documents, and evaluations, and relevant social and economic situations to identify patients' needs.
• Research and identify information needed to perform assessment, respond to questions, or make recommendations.
• Interview providers to obtain information needed to make decisions.
• Identify inconsistencies or illogical information in patient responses, provider orders or patient history information and take appropriate action.
• Apply knowledge of pharmacology and clinical treatment protocol to determine appropriateness of care and instruct patients as needed.
• Work collaboratively with peers/team members and other levels or segments within Optum programs and senior leadership.

Benefits

• Comprehensive benefits package
• Career development opportunities
• Flexible remote work options for Massachusetts residents

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Industry: Insurance Carriers and Related Activities
• Education Level: Bachelor's degree