Sr Utilization Management Nurse – Telecommuter in Massachusetts

UnitedHealth Group • Boston, MA

10d • Remote

About The Position

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together.
We serve the Commonwealth of Massachusetts in partnering with onsite audits and projects. We have collaborative team scheduling and there is an occasional opportunity for remote work based on business needs.
For this role, there will be no weekends, no holidays, and no on-call work.

Requirements

• Undergraduate degree or 4+ years of equivalent nursing experience
• Current unrestricted RN nurse license in Massachusetts
• MDS certification OR must obtain and provide proof prior to start date
• Experience working within medical insurance and/or healthcare industries
• Experience analyzing inventory, researching, identifying, and resolving issues
• Experience with defining and managing processes within a team
• Experience trouble shooting issues for users within teams, IT and or business partners
• Proven knowledge of healthcare insurance industry (Medicaid, Medicare, CMS)
• Proficiency in Microsoft Office
• Ability to travel within geographic territory (state of Massachusetts- Boston and South Shore areas) up to 90%25 of the time and assist when needed throughout the state of Massachusetts for audits. (Audits will be conducted onsite)
• Driver’s License and access to reliable transportation
• Currently reside in Massachusetts

Nice To Haves

• Recent long-term care MMQ, MDS, staff development or management experience (in long-term care)
• Demonstrated knowledge of process flow of UM including prior authorization, concurrent authorization, and/or clinical appeal and guidance reviews
• Proven knowledge of Medicaid and Medicare benefit products including applicable state regulations
• Demonstrated knowledge of applicable area of specialization
• Demonstrated knowledge of Massachusetts DPH guidelines
• Demonstrated knowledge of computer functionality, navigation, and software applications
• All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

Responsibilities

• Audit entire medical record for accuracy of the coding on the MDS/ MMQ to support payment to the nursing facility
• Discuss Patient Care specifics with peers or providers in overall patient care and benefits
• Communicate clinical findings and present rationale for decisions to medical professionals and members at the appropriate level for understanding
• Review the entire medical record for accuracy, and appropriate clinical treatment
• Communicate findings of audits to client, and community as needed
• Education of findings with community, identifying plans for correction
• 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 a given situation
• Perform medical chart review 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 review assessment for accuracy, respond to questions, or make recommendations
• Apply knowledge of pharmacology and clinical treatment protocol to determine appropriateness of care
• Work collaboratively with peers/team members and other levels or segments within Optum, UHC, or UBH (e.g. Case Managers, Field Care Advocates) to identify appropriate course of action (e.g. Appropriate care, follow up course of action, make referral)
• Required to travel within geographic territory 90%25 of the time and assist when needed throughout the state of Massachusetts for audits. (Audits will be conducted onsite)

Benefits

• In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
• No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level