Field-Based RN: Utilization Management & MDS Audit

Mass Digital Health; Springfield (MA); On-site; USD 73,000 - 130,000; Full time

Benefits offered by this job

Comprehensive benefits package

Incentive programs

401k contribution

Job summary

Optum in Springfield, MA seeks a Sr Utilization Management Nurse for field-based audits across the MA region. You will verify MDS coding accuracy, support facility payments, and promote quality patient care. Must travel daily within Massachusetts and maintain HIPAA compliance.

The role emphasizes collaboration with providers, education of stakeholders, and applying clinical expertise to optimize outcomes. Remote work may occur based on business needs.

Qualifications

• Must be a Registered Nurse with a MA license.
• RAC/CT MDS certification required before start date.
• 4+ years in long-term care nursing or medical record review.
• Experience with MMQ, MDS, staff development in long-term care.
• Experience in medical insurance/healthcare industries.
• Strong analytical and problem-solving abilities.
• Demonstrated ability to work with interdisciplinary teams.
• Proven knowledge of Medicaid/Medicare and CMS guidelines.
• Ability to drive within MA for audits; reliable transportation.

Responsibilities

• Audit MDS assessments and medical records for coding accuracy.
• Review antipsychotic use and other clinical indicators for quality.
• Evaluate documentation and treatments with clinical judgement.
• Communicate audit findings to providers and facility leaders.
• Educate facilities on corrective actions and best practices.
• Collaborate with stakeholders to improve care quality.
• Maintain HIPAA compliance and protect PHI.
• Oversee chart reviews to support appropriate care decisions.
• Discuss patient care specifics with peers and providers.
• Identify information needed to review assessments and respond.

Skills

Long-term care nursing experience

Medicare/Medicaid knowledge

Audit / medical record review

Clinical documentation review

Effective communication

Field-based travel readiness

Education

Registered Nurse license (MA)

Tools

Microsoft Office Suite

Job description

Optum in Springfield, MA seeks a Sr Utilization Management Nurse for field-based audits across the MA region. You will verify MDS coding accuracy, support facility payments, and promote quality patient care. Must travel daily within Massachusetts and maintain HIPAA compliance.

The role emphasizes collaboration with providers, education of stakeholders, and applying clinical expertise to optimize outcomes. Remote work may occur based on business needs.