Remote Sr Utilization Management Nurse RN – MA

Optum

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Requisition Number: 2221355
Job Category: Nursing
Primary Location: Boston, MA
(Remote considered)

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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. 

If you are located in the Massachusetts area, you will have the flexibility to work remotely* as you take on some tough challenges. Travel within territory 100% of the time and assist when needed in the state of Massachusetts during audits. (Audits will be conducted onsite removed from patient care areas). There is some opportunity for remote work based on business needs. Collaborative team scheduling!

For the role there will be no weekends, no holidays, and no on-call work.

Primary Responsibilities:

  • Audit entire medical record for accuracy of the coding on the MMQ to support payment to the nursing facility
  • Answer patient questions regarding care (medication, treatment) and benefits
  • Discuss Patient Care specifics with peers or providers in overall patient care and benefits
  • Leverage appropriate clinical terminology when communicating with physicians and other medical professionals
  • Communicate clinical findings and present rationale for decisions to medical professionals and members at the appropriate level for understanding
  • Advocate with physicians and others for appropriate decisions (e.g. patient level of care changes) regarding patient betterment (e.g. care and service coverage, safety)
  • 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 assessment 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 perform assessment, respond to questions, or make recommendations
  • Interview patients/family members or other providers to obtain information needed to make decisions
  • Identify inconsistencies or illogical information in patient responses, provider orders or patient history information and take appropriate action
  • Apply knowledge of pharmacology and clinical treatment protocol to determine appropriateness of care and instruct patients as needed
  • Work collaboratively with peers/team members and other levels or segments within Optum, UHC, or UBH (eg. Case Managers, Field Care Advocates) to identify appropriate course of action (eg. 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:

  • Undergraduate degree or 4+ years of equivalent nursing experience
  • Current unrestricted RN nurse license in Massachusetts
  • MDS Certification or willing to obtain prior to start date
  • 2+ years of experience sorting, summing, creating bar graphs, and formulas within Microsoft Excel
  • Recent long-term care MMQ, MDS, 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
  • Experience gathering and writing business requirements documentation including standard operating procedures
  • Knowledge of healthcare insurance industry (Medicaid, Medicare, CMS)
  • Proven knowledge of Medicaid and Medicare benefit products including applicable state regulations
  • 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 100% of the time and assist when needed though out the state of Massachusetts for audits. (Audits will be conducted onsite removed from patient care areas)

Preferred Qualifications:

  • Demonstrated knowledge of applicable area of specialization
  • Demonstrated knowledge of computer functionality, navigation, and software applications

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy