Sr. Utilization Management Nurse RN - Field Position

Improve the lives of others while Caring. Connecting. Growing together.

Job Description
- Sr. Utilization Management Nurse RN
- Field Position (2390818)

Sr. Utilization Management Nurse RN
- Field Position - 2390818

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.

This is a Field-Based role for the state of Massachusetts. Qualified candidates must live in the Boston MA Regional Area, driving daily to different facility locations in the region/state. For this role, there will be no weekends, no holidays, and no on-call work.

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.

• As a Field-Based position, this role requires daily driving within geographic territory (state of Massachusetts) at least 90% of the time (some weeks will require 100% as business needs dictate) and assist when needed throughout the state of Massachusetts for audits. (Audits will be conducted onsite)
• Audit MDS assessments and medical records to validate coding accuracy, quality outcomes, and reimbursement integrity
• Review antipsychotic medication use and other clinical indicators to support quality improvement initiatives
• Evaluate clinical documentation, treatments, and medication utilization using demonstrated clinical judgment and regulatory knowledge
• Communicate audit findings and recommendations to providers, facility leaders, and interdisciplinary teams
• Educate nursing facilities on corrective actions, best practices, and compliance standards
• Partner with internal and external stakeholders to improve care quality and patient outcomes
• Maintain strict compliance with HIPAA and all applicable privacy and confidentiality requirements
• 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
• Review the entire medical record for accuracy, and appropriate clinical treatment
• 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…