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 Springfield 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 Springfield 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)
Youll 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 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
Must live in the Springfield MA Regional Area to conduct daily field-based travel requirements
Ability to drive daily to different locations 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)
Must have reliable transportation and be able to provide proof of a valid, unrestricted Drivers License and current Auto Insurance
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
Proficiency with Microsoft Office Suite
Proficient written and verbal skills
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, youll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 - $130,000 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.