Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team 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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

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.

The Manager Utilization Management provides the oversight and education of the team (shares findings, generates new ideas and opportunities, and develops education) to help the team be unified in their decisions. This role shares management jointly with the Associate Director (AD) and another team manager. Together they will cover, as assigned, for the AD when the AD is involved with leadership, PTO, or other work. The Manager will be required to travel to serve the needs of the client, and may also include occasional overnight stays as needed, throughout the state of Massachusetts for audits. (Audits will be conducted onsite).

No weekend hours or rotation, no major holiday’s, no on call.

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

Primary Responsibilities:

• Supports the team by answering questions, guiding, leading by example but no-one directly reports to this role
• Support the quality outcomes of audits
• Assist team remotely and onsite with administrative tasks as needed
• Audit entire medical record for accuracy of the coding on the MMQ/MDS, to support accuracy and payment to the nursing facility
• Utilize technology and support team in EMR programs (PCC, Matrix, EPIC, etc)
• Answer staff questions regarding care (medication, treatment) and benefits
• Discuss Patient Care specifics with peers or providers in overall patient care and benefits
• Apply knowledge of pharmacology and clinical treatment protocol to determine appropriateness of care
• Leverage appropriate clinical terminology when communicating with customers
• Communicate clinical findings and present rationale for decisions to medical professionals and members at the appropriate level for understanding
• Work collaboratively with peers/team members and other levels or segments within Optum, UHC
• 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 each situation
• Perform onsite and remote quality review of assessments 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 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 programs and senior leadership

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
• Active MDS Certification
• 3+ years of previous Long-Term experience preferred in an Education/Supervisory/Management Role
• 1+ years of experience and knowledge of MMQ and MDS
• 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
• Demonstrated knowledge of applicable area of specialization MMQ/MDS/LTC Regulations
• Demonstrated knowledge of computer functionality, navigation, and software applications
• Proven ability to assess, review and apply criteria (eg. Milliman guidelines, CMS criteria, medical policy)
• Proven ability to travel in the state of Massachusetts up to 75% of the time (Day travel for onsite/remote quality review audits of each team member is required per MMQ/MDS cycle

Preferred Qualification:

• Demonstrated knowledge of process flow of UM including, clinical appeals and guidance reviews

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe 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 experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

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.