Sr Utilization Management Nurse RN - Remote

UnitedHealth Group•Boston, MA

27d•$72,800 - $130,000•Hybrid

About The Position

As a Sr Utilization Management Nurse in the Boston MA Regional Area, the role centers on ensuring the accuracy of medical record coding, supporting proper payment to nursing facilities, and promoting quality patient care. Responsibilities include collaborating with peers and providers to discuss care details, reviewing clinical information for appropriateness, and communicating findings and rationale to medical professionals and the broader community. Additionally, the nurse educates stakeholders about audit results and corrective plans, ensures compliance with HIPAA guidelines, and leverages clinical expertise to guide decisions and optimize patient outcomes. Qualified candidates must live in the Boston MA Regional Area to perform the daily travel responsibilities. For this role, there will be no weekends, no holidays, and no on-call work. If you live in Boston MA, you will have the flexibility to work remotely as you take on some tough challenges.

Requirements

Registered Nurse (RN) with a current, active, unrestricted RN License in Massachusetts
Currently have OR be able to obtain an RAC/CT MDS certification (must have completed certification prior to start date)
4+ years of nursing experience, specifically in long-term care and/or medical record review with knowledge of Medicare and Medicaid
Recent long-term care MMQ, MDS, staff development or management experience (in long-term care)
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)
Demonstrated knowledge of process flow of UM, including prior authorization, concurrent authorization, and/or clinical appeal and guidance reviews
Must live in the Boston MA Regional Area to conduct daily travel requirements
Ability to travel within geographic territory (state of Massachusetts) at least 90%25 of the time (some weeks will require 100%25 travel as business needs dictate) and assist when needed throughout the state of Massachusetts for audits. (Audits will be conducted onsite)
Must have reliable transportation and be able to provide proof of a valid, unrestricted Driver’s License and current Auto Insurance

Nice To Haves

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
Proficiency with Microsoft Office Suite
Proficient written and verbal skills

Responsibilities

Audit entire medical record for accuracy of the coding on the MDS to support payment to the nursing facility
Auditing anti-psychotic therapy for quality review
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 (state of Massachusetts) at least 90%25 of the time (some weeks will require 100%25 travel as business needs dictate) and assist when needed throughout the state of Massachusetts for audits. (Audits will be conducted onsite)