Sr. Utilization Management Nurse RN - Field Position

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.

Primary Responsibilities:

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 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) 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…