Sr Utilization Management Nurse RN - Remote

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities.

Come make an impact on the communities we serve as you help us advance health optimization on a global scale. 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.

If you live in Boston MA, you will have the flexibility to work remotely
* as you take on some tough challenges.

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:

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…