Sr Utilization Management Nurse

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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.
For the 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.

If you are located in Massachusetts, 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/ MMQ to support payment to the nursing facility
• 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 75% of the time 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

• Undergraduate degree or 4+ years of equivalent nursing experience
• Current unrestricted RN nurse license in Massachusetts
• MDS certification or must obtain and provide proof prior to start date
• 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
• Proficient in Microsoft Office
• Proficient written and verbal skills
• Ability to travel within geographic territory (state of Massachusetts) up to 90% of the time and assist when needed throughout the state of Massachusetts for audits. (Audits will be conducted onsite)
• Driver's License and access to reliable transportation

Preferred Qualifications

• 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
• All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy.

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $71,200 to $127,200 annually based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
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