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)
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:- 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 Driver's 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, you'll 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.
