UnitedHealth Group - Plymouth, MA
posted about 1 month ago
Full-time - Mid Level
Remote - Plymouth, MA
Insurance Carriers and Related Activities
About the position
The Senior Utilization Management Nurse role at UnitedHealth Group involves auditing medical records for accuracy, communicating clinical findings, and collaborating with healthcare professionals to ensure appropriate patient care. This remote position, available to candidates in Massachusetts, emphasizes the importance of health equity and aims to improve health outcomes through effective utilization management practices. The role requires significant travel within the state for onsite audits, with no weekend or holiday work expected.
Responsibilities
- Audit entire medical record for accuracy of the coding on the MDS/MMQ to support payment to the nursing facility
- 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
- Educate the community on findings, 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
- Perform medical chart review that includes a review of 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 or segments within Optum, UHC, or UBH to identify appropriate course of action.
Requirements
- Undergraduate degree or 4+ years of equivalent nursing experience
- Current unrestricted RN nurse license in Massachusetts
- MDS certification or must obtain and provide proof prior to start date
- 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 troubleshooting issues for users within teams, IT and/or business partners
- Preferred 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
Nice-to-haves
- 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
Benefits
- Comprehensive benefits package
- Career development opportunities
- Diversity and inclusion culture
