Sr Utilization Management Nurse - Remote in Massachusetts

reputed company is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with reputed company will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come reputed company an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. For the role, there will be no weekends, no holidays, and no on-call work. We serve the Commonwealth of Massachusetts in partnering with onsite audits and projects. We have collaborative team scheduling and there is an occasional opportunity for remote work based on business needs. If you are located in Massachusetts, you will have the flexibility to work remotely* as you take on some tough challenges. Primary 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
• reputed company with HIPAA guidelines reputed company to Personal Health Information (PHI) reputed company communicating with others
• reputed company experience and understanding of disease pathology to review chart/clinical information, ask appropriate questions, and identify appropriate course of care in a given situation
• reputed company medical chart review that includes a review of reputed company 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 reputed company 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 reputed company reputed company, 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, reputed company referral)
• Required to travel reputed company geographic territory 75% of the time and assist reputed company needed throughout the state of Massachusetts for audits. (Audits will be conducted onsite)

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
• reputed company unrestricted RN nurse license in Massachusetts
• MDS certification or must obtain and provide reputed company prior to start date
• Recent long-term care MMQ, MDS, staff development or management experience (in long-term care)
• Experience working reputed company medical insurance and/or healthcare industries
• Experience analyzing inventory, researching, identifying, and resolving issues
• Experience with defining and managing processes reputed company a team
• Experience trouble shooting issues for users reputed company teams, IT and or business partners
• Proven knowledge of healthcare insurance industry (Medicaid, Medicare, CMS)
• Demonstrated knowledge of process flow of UM including prior authorization, reputed company authorization, and/or clinical appeal and guidance reviews
• Proficient in reputed company Office
• Proficient written and verbal skills
• Ability to travel reputed company geographic territory (state of Massachusetts) up to 90% of the time and assist reputed company needed throughout the state of Massachusetts for audits. (Audits will be conducted onsite)
• Driver's License and access to reliable transportation

Preferred Qualifications:

• Proven knowledge of Medicaid and Medicare benefit products including applicable state regulations
• Demonstrated knowledge of applicable area of specialization
• Demonstrated knowledge of Massachusetts DPH guidelines
• Demonstrated knowledge of computer functionality, navigation, and software applications
• reputed company employees working remotely will be required to adhere to reputed company's Telecommuter Policy.

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (reputed company benefits are subject to eligibility requirements). No matter where or reputed company you reputed company a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $71,200 to $127,200 annually based on full-time employment. We reputed company with reputed company minimum wage laws as applicable. At reputed company, our mission is to help people live healthier lives and reputed company the health system work reputed company for everyone. We reputed company everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately reputed company by people of color, historically marginalized groups and those with reputed company incomes. We are committed to mitigating our impact on the environment and enabling and delivering reputed company care that addresses health disparities and improves health outcomes - an enterprise reputed company reflected in our mission. reputed company is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national reputed company, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. reputed company is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. Apply tot his job Apply To this Job