Optum, a global leader in healthcare innovation, is dedicated to enhancing the wellbeing of millions through technology-driven solutions. Join our dynamic team and play a pivotal role in transforming health outcomes by connecting individuals with essential care, pharmacy benefits, and valuable resources that empower them to thrive. At Optum, you will be immersed in a culture that values diversity and inclusion, collaborates with skilled professionals, and offers comprehensive benefits alongside opportunities for professional growth. Be part of our mission to drive health equity on a global scale and help us make a difference in the communities we serve. Together, let’s embark on a journey of Caring. Connecting. Growing together.

Our focus extends to the Commonwealth of Massachusetts, where we engage in critical onsite audits and initiatives. Our team-oriented approach allows for collaborative scheduling, with occasional opportunities for remote work based on business needs.

In this role, you will enjoy a work-life balance with no weekends, holidays, or on-call duties. If you’re based in Massachusetts, you’ll have the advantage of working remotely while tackling significant challenges in healthcare.

Key Responsibilities:

• Conduct thorough audits of medical records to ensure coding accuracy on MDS/MMQ for nursing facility payments.
• Collaborate with colleagues and healthcare providers to discuss detailed aspects of patient care and benefits.
• Clearly communicate clinical findings and rationalize decisions to medical professionals and members in an accessible manner.
• Review complete medical records to verify accuracy and assess appropriate clinical treatments.
• Relay audit findings to clients and the community when necessary.
• Educate community stakeholders on findings and collaborate on corrective action plans.
• Maintain compliance with HIPAA regulations concerning Personal Health Information (PHI).
• Utilize your understanding of disease pathology to evaluate clinical information and formulate appropriate care plans.
• Conduct medical chart reviews that encompass current and past patient conditions, documents, evaluations, and relevant socio-economic factors to identify patient needs.
• Investigate and source information required for audit assessments, responding to queries and providing recommendations.
• Apply pharmacological knowledge and clinical treatment guidelines to evaluate care appropriateness.
• Work collaboratively across various departments within Optum, UHC, or UBH, ensuring effective identification and action regarding patient care needs.
• Travel within your designated territory approximately 75% of the time, conducting onsite audits throughout Massachusetts.

What You Bring:
Required Qualifications:

• Undergraduate degree or equivalent nursing experience (4+ years).
• Current, unrestricted RN license in Massachusetts.
• MDS certification, or the ability to obtain one prior to the start date.
• Experience in healthcare or medical insurance industries.
• Proven ability in analyzing inventory, researching, identifying, and resolving issues.
• Background in defining and managing team processes.
• Proficiency in Microsoft Office Suite.
• Strong written and verbal communication skills.
• Willingness to travel within Massachusetts for onsite audits.

Preferred Qualifications:

• Recent experience in long-term care MMQ, MDS, or staff development/management.
• Expertise in troubleshooting user issues within teams or with IT/business partners.
• In-depth knowledge of Medicaid and Medicare benefits and state regulations.
• Familiarity with Massachusetts Department of Public Health guidelines.
• Competence in navigating computer functionalities and software applications.

Employees working remotely must adhere to UnitedHealth Group’s Telecommuter Policy.

Compensation:
The salary range for this position is between $71,600 and $140,600 annually for full-time employment, influenced by local labor market conditions, education, experience, and certifications. UnitedHealth Group guarantees compliance with all applicable minimum wage laws. In addition to your salary, we offer a competitive benefits package that includes incentive programs, equity stock purchase options, and 401k contributions, all subject to eligibility requirements. Regardless of when or where you begin your career with us, you’ll find a wide array of benefits and incentives designed to support your success.

Our Mission:
At UnitedHealth Group, our commitment is to empower individuals to lead healthier lives and optimize the health system for all. We believe in equitable access to health, irrespective of race, gender, sexuality, age, geographical location, or economic status. We strive to break down barriers to good health, especially for marginalized communities and those facing economic challenges. Our dedication to environmental sustainability and equitable healthcare delivery aligns with our core mission to enhance health outcomes.

Equal Opportunity Employer:
UnitedHealth Group is an equal employment opportunity employer, and we welcome applications from qualified candidates without regard to race, national origin, religion, age, color, gender identity, sexual orientation, disability, veteran status, or any other characteristic protected by law.

Drug-Free Workplace:
Candidates are required to complete a drug test prior to employment.