Sr Utilization Management Nurse – Remote (Massachusetts)
Join to apply for the Sr Utilization Management Nurse – Remote in Massachusetts role at Optum .
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.
For this role, there will be no weekends, no holidays, and no on‑call work. We are based in Massachusetts and offer the flexibility to work remotely for eligible employees as you take on challenging day‑to‑day projects. Some on‑site audits may be required, and travel within the state of Massachusetts may be needed up to 75% of the time.
Primary Responsibilities
Audit the medical record for accuracy of MDS/MMQ coding to support payment to the nursing facility.
Discuss patient care specifics with peers or providers to improve overall patient care and benefits.
Communicate clinical findings and present rationale for decisions to medical professionals and members at an appropriate level of understanding.
Review the entire medical record for accuracy, appropriate clinical treatment and ensure compliance with HIPAA guidelines related to PHI.
Leverage expertise in disease pathology to review chart/clinical information, ask appropriate questions, and identify appropriate course of care.
Perform medical chart review that includes current and prior patient conditions, documents, 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 within Optum, UHC or UBH to identify appropriate course of action and make referrals.
Required to travel within geographic territory 75% of the time and assist when needed throughout the state of Massachusetts for audits.
Required Qualifications
Undergraduate degree or 4+ years of equivalent nursing experience.
Current unrestricted RN nurse license in Massachusetts.
MDS certification or obtain by start date.
Recent long‑term care MMQ, MDS, staff development or management experience.
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 troubleshooting 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 up to 90% of the time for audits.
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 ranges from $71,200 to $127,200 annually based on full‑time employment. In addition to salary, we offer a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone 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.