Senior Utilization Management Nurse - Field Role

Join Optum, a global leader in healthcare innovation, where your work will directly contribute to improving health outcomes for millions. In this role, you will engage with communities to provide essential care, pharmacy benefits, and resources, all while enjoying a culture of inclusion and collaboration. Discover opportunities for career development and comprehensive benefits as you embark on a fulfilling journey of Caring. Connecting. Growing together.

This is a vital field-based position for candidates residing in Massachusetts. You will drive to various facility locations throughout the state while enjoying a schedule that respects your personal time with no weekends, holidays, or on-call demands.

As a Senior Utilization Management Nurse, your focus will be on ensuring coding accuracy in medical records, supporting proper reimbursements to nursing facilities, and enhancing overall patient care quality. This role involves collaborating with peers and providers, reviewing clinical information for appropriateness, communicating insights to medical professionals, and educating stakeholders on audit results and corrective plans while maintaining HIPAA compliance.

Key Responsibilities:
• Conduct daily driving within Massachusetts (90% of the time, with potential for 100% as needed), assisting with onsite audits across the state.
• Audit MDS assessments and medical records for coding accuracy and reimbursement integrity.
• Evaluate the use of antipsychotic medications and other clinical indicators to advance quality improvement efforts.
• Communicate findings and recommendations effectively to providers, facility leaders, and interdisciplinary teams.
• Educate nursing facilities on best practices, compliance standards, and corrective actions.
• Work with internal and external stakeholders to drive improvements in care quality and patient outcomes.
• Maintain strict confidentiality in compliance with HIPAA regulations.
• Review the entire medical record to ensure coding accuracy and appropriate clinical treatment.
• Leverage clinical expertise to guide care decisions and optimize patient outcomes.
• Collaborate with peers and other members of the Optum team to determine appropriate courses of action.

You will be rewarded for your performance in a challenging environment that offers clear pathways to success in your current role and future opportunities.

Required Qualifications:
• Active, unrestricted Registered Nurse (RN) License in Massachusetts.
• Certification in RAC/CT MDS or ability to obtain prior to the start date.
• At least 4 years of nursing experience focused on long-term care and medical record review, including Medicare and Medicaid knowledge.
• Recent experience in long-term care MMQ, MDS, staff development, or management.
• Experience within medical insurance and the healthcare landscape.
• Ability to analyze, research, and resolve issues effectively.
• Proven knowledge of healthcare insurance processes, including UM and clinical appeals.
• Must reside in the Springfield MA regional area to fulfill daily travel requirements.
• Reliable transportation and proof of valid driver's license and auto insurance required.

Preferred Qualifications:
• Expertise in Medicaid and Medicare benefits and Massachusetts DPH guidelines.
• Proficiency with Microsoft Office and strong communication skills.
• Demonstrated relevant computer application knowledge.

The salary for this role ranges from $72,800 - $130,000 annually based on qualifications. We offer a comprehensive benefits package, including performance-based incentives, stock purchase options, and a 401k plan.

At UnitedHealth Group, our mission is to ensure everyone has access to better health outcomes. We are dedicated to creating a diverse environment and are proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, disability, or veteran status.

UnitedHealth Group is a drug-free workplace. Candidates must pass a drug test as a condition of employment.