Remote Utilization Management RN — Audits & Care Optimization

Optum

Worcester (MA)

On-site

USD 85,000 - 110,000

Full time

14 days+

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Job summary

UnitedHealth Group in Massachusetts seeks a registered nurse auditor to review MDS/MMQ coding for facility payments. This role involves 75% travel across the state with occasional remote work based on business needs.

You will audit medical records, discuss care plans, present findings and ensure HIPAA compliance. The ideal candidate holds an undergraduate degree or 4+ years nursing experience, a MA RN license, MDS/MMQ certification, and long-term care/health insurance experience.

Qualifications

Undergraduate degree or 4+ years of equivalent nursing experience.
Current unrestricted RN 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.

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.
Education of findings with community, 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, 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).
Required to travel within geographic territory 75% of the time and assist when needed throughout the state of Massachusetts for audits. (Audits will be conducted onsite)