Senior RN – Field Utilization Management (MA)

Optum; Amherst (MA); On-site; USD 73,000 - 130,000; Full time

Job summary

Optum is seeking a Sr Utilization Management Nurse for the Springfield MA region. This field-based role focuses on ensuring accurate medical record coding, supporting proper payments to nursing facilities, and promoting quality patient care across the state.

You will drive daily within Massachusetts, review MDS charts, collaborate with providers and facility leaders, and educate stakeholders on audit results and corrective actions while maintaining HIPAA compliance and patient confidentiality.

Qualifications

• Must be a MA-licensed RN with unrestricted license.
• 4+ years nursing experience in long-term care or medical record review.
• Experience with Medicare/Medicaid knowledge and audits.

Responsibilities

• Daily driving within MA territory (90-100%)
• Audit MDS assessments and medical records to validate coding accuracy, quality outcomes, and reimbursement integrity
• Review antipsychotic medication use and other clinical indicators to support quality improvement initiatives
• Evaluate clinical documentation, treatments, and medication utilization using clinical judgment
• Communicate audit findings and recommendations to providers and facility leaders
• Educate nursing facilities on corrective actions, best practices, and compliance standards
• Partner with internal and external stakeholders to improve care quality and patient outcomes
• Maintain HIPAA compliance and privacy requirements
• Audit entire medical record for accuracy of the coding on the MDS to support payment to the nursing facility
• Auditing anti-psychotic therapy for quality review
• Discuss Patient Care specifics with peers or providers in overall patient care and benefits
• Review the entire medical record for accuracy, and appropriate clinical treatment
• Comply with HIPAA guidelines related to PHI when communicating with others
• Leverage experience to review chart/clinical information and identify appropriate course of care
• Perform medical chart review including social/economic situations to identify patient needs
• Research information needed to review assessment for accuracy and make recommendations
• Apply knowledge of pharmacology and clinical treatment protocol to determine appropriateness of care
• Work with Optum/UBH teams to determine appropriate course of action

Skills

RN License MA

MDS Audit

Medicare/Medicaid

Field-based travel

HIPAA compliance

Communication skills

Team collaboration

Education

Registered Nurse License (MA)

MDS Certification or RAC/CT (preferred)

Tools

Microsoft Office Suite

Job description

Optum is seeking a Sr Utilization Management Nurse for the Springfield MA region. This field-based role focuses on ensuring accurate medical record coding, supporting proper payments to nursing facilities, and promoting quality patient care across the state.

You will drive daily within Massachusetts, review MDS charts, collaborate with providers and facility leaders, and educate stakeholders on audit results and corrective actions while maintaining HIPAA compliance and patient confidentiality.