Senior Utilization MDS/MMQ Management Nurse RN - Western Massachusetts

Company: UnitedHealth Group
Location: Chicopee
Posted on: May 16, 2022

Job Description:

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. Travel within territory 100% of the time and assist when needed in the state of Massachusetts during audits (9 out of 12 months of the year) (Audits will be conducted onsite removed from patient care areas); the other 3 out of 12 months you will be home.
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 long-term care MMQ, MDS, or management experience (in long-term care) experience
Experience assessing, reviewing and applying criteria (eg. Milliman guidelines, CMS criteria, medical policy)
Knowledge of healthcare insurance industry products (eg. HMO, PPO, ASO)
Knowledge of Medicaid and Medicare benefit products including applicable state regulations
Demonstrate knowledge of process flow of UM including prior authorization, concurrent authorization, and/or clinical appeal and guidance reviews
Ability to travel within territory 100% of the time and assist when needed in the state of Massachusetts during audits (9 out of 12 months of the year) (Audits will be conducted onsite removed from patient care areas); the other 3 out of 12 months you will primarily be home-based with remote work -including July and December.
Full COVID-19 vaccination is an essential requirement of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance
Preferred Qualifications:
Demonstrate knowledge of applicable area of specialization
Demonstrate knowledge of computer functionality, navigation, and software applications

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.
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.

Keywords: UnitedHealth Group, Chicopee , Senior Utilization MDS/MMQ Management Nurse RN - Western Massachusetts, Healthcare , Chicopee, Massachusetts