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UnitedHealth Group Senior Utilization MMQ Management Nurse RN - Danvers, Beverly, Newbury Port, Peabody area 75% Travel in this Area in Danvers, Massachusetts

Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that's improving the lives of millions. Here, innovation isn't about another gadget, it's about making health care data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life's best work.(sm)

If you are located in the Massachusetts area, you will have the flexibility to telecommute* as you take on some tough challenges.

Primary Responsibilities:

  • Audit entire medical record for accuracy of the coding on the MMQ to support payment to the nursing facility

  • Answer patient questions regarding care (medication, treatment) and benefits

  • Discuss Patient Care specifics with peers or providers in overall patient care and benefits

  • Leverage appropriate clinical terminology when communicating with physicians and other medical professionals

  • Communicate clinical findings and present rationale for decisions to medical professionals and members at the appropriate level for understanding

  • Advocate with physicians and others for appropriate decisions (e.g. patient level of care changes) regarding patient betterment (e.g. care and service coverage, safety)

  • 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 assessment 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 perform assessment, respond to questions, or make recommendations

  • Interview patients / family members or other providers to obtain information needed to make decisions

  • Identify inconsistencies or illogical information in patient responses, provider orders or patient history information and take appropriate action

  • Apply knowledge of pharmacology and clinical treatment protocol to determine appropriateness of care and instruct patients as needed

  • Work collaboratively with peers / team members and other levels or segments within Optum, UHC, or UBH (eg. Case Managers, Field Care Advocates) to identify appropriate course of action (eg. Appropriate care, follow up course of action, make referral)

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

  • Undergraduate degree or 4+ years of equivalent nursing experience

  • Current unrestricted RN nurse license in Massachusetts

  • 1+ years of previous long-term care MMQ, MDS, or DON / Supervisory (in long-term care) experience

  • Ability to assess, review and apply criteria (eg. Milliman guidelines, CMS criteria, medical policy)

  • Knowledge of national clinical practice guidelines (eg. Disease management)

  • Knowledge of healthcare insurance industry products (eg. HMO, PPO, ASO)

  • Knowledge of Medicaid and Medicare benefit products including applicable state regulations

  • Demonstrate knowledge of applicable area of specialization

  • Demonstrate knowledge of computer functionality, navigation, and software applications

  • Demonstrate knowledge of process flow of UM including prior authorization, concurrent authorization, and/or clinical appeal and guidance reviews

  • Ability to travel in the state of Massachusetts 75% of the time (Audits will be conducted onsite removed from patient care areas and also conducted remotely)

  • You will be provisioned with appropriate Personal Protective Equipment (PPE) and are required to perform this role with patients and members on site, as this is an essential function of this role

  • Employees are required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group-approved symptom screener prior to entering the work site each day, in order to keep our work sites safe. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Job Keywords: RN, registered nurse, management, Essex County, Middlesex County, Plymouth, Reading, Wilmington, Quincy, Milford, Gloucester, MA, Massachusetts, telecommute, remote, work from home