Remote Utilization Management RN – MA Travel 75%

Optum; Kingston (MA); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Optum is seeking a licensed RN with MDS/MMQ expertise to audit medical records for accuracy and to support facility payments. You will discuss patient care details with peers and providers, present findings to medical professionals, and ensure HIPAA compliance.

The role requires extensive travel within Massachusetts for audits and collaborates with care teams to determine appropriate courses of action. This position emphasizes accuracy, clinical judgment, and coordination with UHC/UBH teams,

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 defining and managing processes within a team.
• Experience traveling within geographic territory 75% of the time for audits in Massachusetts.

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 to identify appropriate course of action.
• 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)

Skills

Verbal communication

Written communication

Microsoft Office

Team process management

Education

RN license (Massachusetts)

MDS certification

Long-term care MMQ/MDS experience

Tools

Microsoft Office

Job description

Optum is seeking a licensed RN with MDS/MMQ expertise to audit medical records for accuracy and to support facility payments. You will discuss patient care details with peers and providers, present findings to medical professionals, and ensure HIPAA compliance.

The role requires extensive travel within Massachusetts for audits and collaborates with care teams to determine appropriate courses of action. This position emphasizes accuracy, clinical judgment, and coordination with UHC/UBH teams,