Sr. Utilization Management Nurse - Field RN; Massachusetts

Position: Sr. Utilization Management Nurse - Field RN (Massachusetts)
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.

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.

Primary 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% of the time (some weeks will require 100% travel as business needs dictate) and assist when needed throughout the state of Massachusetts for audits. (Audits will be conducted onsite)

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Must be a Registered Nurse (RN) with a current, active, unrestricted RN License in Massachusetts
• Must 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…