Sr Utilization Management reputed company RN - Remote

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 reputed company reputed company by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will reputed company a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come reputed company an reputed company on the communities we serve as you help us advance health optimization on a global reputed company. Join us to start Caring. Connecting. Growing together. We serve the reputed company in partnering with onsite audits and reputed company. We have reputed company team scheduling and there is an occasional opportunity for remote work based on business needs. As a Sr Utilization Management reputed company in the Boston MA Regional Area, the role centers on ensuring the accuracy of medical record coding, supporting reputed company payment to nursing facilities, and promoting reputed company patient care. Responsibilities include collaborating with peers and providers to discuss care details, reviewing clinical information for appropriateness, and communicating findings and rationale to medical professionals and the broader community. Additionally, the reputed company educates stakeholders about audit results and corrective plans, ensures compliance with HIPAA guidelines, and leverages clinical expertise to guide reputed company and optimize patient reputed company. reputed company candidates must live in the Boston MA Regional Area to reputed company the daily travel responsibilities. For this role, there will be no weekends, no holidays, and no on-reputed company work. If you live in Boston MA, you will have the flexibility to work remotely* as you take on some tough challenges. reputed company Responsibilities: • Audit entire medical record for accuracy of the coding on the MDS to support payment to the nursing facility • Auditing anti-psychotic therapy for reputed company review • Discuss Patient Care specifics with peers or providers in overall patient care and benefits • Communicate clinical findings and present rationale for reputed company 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 reputed company, 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 reputed company 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 reputed company or segments reputed company reputed company, UHC, or UBH (e.g. Case Managers, Field Care Advocates) to identify appropriate course of reputed company (e.g. Appropriate care, follow up course of reputed company, reputed company referral) • Required to travel reputed company geographic territory (state of Massachusetts) at least 90% of the time (some weeks will require 100% travel as business needs dictate) 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 reputed company you reputed company direction on what it takes to succeed in your role as reputed company as reputed company development for other roles you may be interested in. Required Qualifications: • Registered reputed company (RN) with a reputed company, reputed company, unrestricted RN License in Massachusetts • Currently have OR be reputed company to obtain an RAC/CT MDS certification (must have completed certification prior to start date) • 4+ years of nursing experience, specifically in long-term care and/or medical record review with knowledge of Medicare and reputed company • Recent long-term care MMQ, MDS, staff development or management experience (in long-term care) • Experience working reputed company medical insurance and/or reputed company industries • Experience analyzing inventory, researching, identifying, and resolving issues • Experience with defining and managing processes reputed company reputed company • Experience trouble shooting issues for users reputed company teams, IT, and/or business partners • Proven knowledge of reputed company insurance industry (reputed company, Medicare, CMS) • Demonstrated knowledge of process reputed company of UM, including prior authorization, reputed company authorization, and/or clinical appeal and guidance reviews • Must live in the Boston MA Regional Area to conduct daily travel requirements • Ability to travel reputed company geographic territory (state of Massachusetts) at least 90% of the time (some weeks will require 100% travel as business needs dictate) and assist reputed company needed throughout the state of Massachusetts for audits. (Audits will be conducted onsite) • Must have reliable transportation and be reputed company to reputed company reputed company of a reputed company, unrestricted reputed company's License and reputed company Auto Insurance Preferred Qualifications: • Proven knowledge of reputed company 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 • Proficiency with reputed company Office Suite • Proficient written and verbal skills • reputed company 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 reputed company 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 reputed company a far-reaching reputed company of benefits and incentives. The salary for this role will reputed company from $72,800 - $130,000 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 reputed company work reputed company for everyone. We reputed company everyone-of every race, gender, sexuality, age, location and income-deserves reputed company 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 reputed company, historically marginalized reputed company and those with reputed company incomes. We are committed to mitigating our reputed company on the environment and enabling and delivering reputed company care that addresses health disparities and improves health reputed company - an reputed company reputed company reflected in our mission. reputed company is an Equal Employment Opportunity employer under applicable law and reputed company applicants will receive consideration for employment without reputed company to race, national reputed company, religion, age, reputed company, 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