Senior Utilization Management RN – Remote & Field Audit Lead

Optum; Boston (MA); Hybrid; USD 72,800 - 130,000; Full time

Job summary

Optum is seeking a Sr Utilization Management Nurse in the Boston, MA region to ensure accuracy in medical record coding, support appropriate payments to nursing facilities, and promote quality patient care. Travel within Massachusetts is required, with occasional remote work based on business needs.

The role requires an active MA RN license, RAC/CT MDS certification, and 4+ years in long-term care or medical record review, with knowledge of Medicare/Medicaid.

Qualifications

• Registered Nurse (RN) with a current, active, unrestricted RN License in Massachusetts.
• Must have OR be able to obtain RAC/CT MDS certification before start date.
• 4+ years nursing experience, specifically in long-term care and/or medical record review with knowledge of Medicare/Medicaid.
• Experience in long-term care MMQ, MDS, staff development or management.
• Experience in medical insurance/healthcare industries and CMS/Medicaid knowledge.
• Able to travel 90% of the time within Massachusetts; valid driver’s license and auto insurance.

Responsibilities

• Audit entire medical record for accuracy of the coding on the MDS to support payment to the nursing facility.
• Audit anti-psychotic therapy for quality review.
• Discuss patient care specifics with peers/providers and communicate findings to medical professionals and community.
• Educate stakeholders about audit findings and corrective plans; ensure HIPAA compliance.
• Collaborate with Case Managers, Field Care Advocates, and other Optum/UBH teams to determine appropriate care and follow-up actions.
• Travel within Massachusetts to perform audits onsite as required.

Skills

RN licensure MA

4+ years LTC experience

Medicare/Medicaid knowledge

MDS/audit experience

HIPAA compliance

Education

RN (Massachusetts)

Tools

MDS auditing tools

Job description

Optum is seeking a Sr Utilization Management Nurse in the Boston, MA region to ensure accuracy in medical record coding, support appropriate payments to nursing facilities, and promote quality patient care. Travel within Massachusetts is required, with occasional remote work based on business needs.

The role requires an active MA RN license, RAC/CT MDS certification, and 4+ years in long-term care or medical record review, with knowledge of Medicare/Medicaid.