Sr Utilization Management Nurse RN - Remote

About the role

The Sr Utilization Management Nurse role focuses on ensuring the accuracy of medical record coding, supporting proper payment to nursing facilities, and promoting quality patient care. This position requires collaboration with peers and providers, auditing clinical information, communicating findings, and educating stakeholders.

Responsibilities

• 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
• 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
• 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)

Requirements

• 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 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
• Proven knowledge of healthcare insurance industry (Medicaid, Medicare, CMS)
• Must live in the Boston MA Regional Area to conduct daily travel requirements
• Ability to travel 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)
• Reliable transportation and be able to provide proof of a valid, unrestricted Driver's License and current Auto Insurance

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
• Proven knowledge of process flow of UM, including prior authorization, concurrent authorization, and/or clinical appeal and guidance reviews

Benefits

Comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution (all benefits are subject to eligibility requirements).