12 jobs found

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? 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. As a Sr Utilization Management Nurse in the Boston MA Regional Area, the role centers on ensuring the accuracy of medical record coding, supporting proper payment to nursing facilities, and promoting quality 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 nurse educates stakeholders about audit results and corrective plans, ensures compliance with HIPAA guidelines, and leverages clinical expertise to guide decisions and optimize patient outcomes. Qualified candidates must live in the Boston MA Regional Area to perform the daily travel responsibilities. For this role, there will be no weekends, no holidays, and no on-call work. Primary 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 quality review 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 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 medical chart review 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 review assessment for accuracy, respond to questions, or make 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 within Optum, 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, make referral) Required to travel within geographic territory (state of Massachusetts) at least 90% of the time (some weeks will require 100% travel as business needs dictate) and assist when 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: Must be a Registered Nurse (RN) with a current, active, unrestricted RN License in Massachusetts Must currently have OR be able 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 Medicaid Recent long-term care MMQ, MDS, staff development or management experience (in long-term care) Experience working within medical insurance and/or healthcare industries Experience analyzing inventory, researching, identifying, and resolving issues Experience with defining and managing processes within a team Experience trouble shooting issues for users within 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, concurrent authorization, and/or clinical appeal and guidance reviews Must live in the Boston MA Regional Area to conduct daily travel requirements Ability to travel within geographic territory (state of Massachusetts) at least 90% of the time (some weeks will require 100% travel as business needs dictate) and assist when needed throughout the state of Massachusetts for audits. (Audits will be conducted onsite) Must have reliable transportation and be able to provide proof of a valid, unrestricted Driver's License and current Auto Insurance 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 Proficiency with Microsoft Office Suite Proficient written and verbal skills 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 (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 to $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable. Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. 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. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, 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. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? 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. As a Sr Utilization Management Nurse in the Boston MA Regional Area, the role centers on ensuring the accuracy of medical record coding, supporting proper payment to nursing facilities, and promoting quality 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 nurse educates stakeholders about audit results and corrective plans, ensures compliance with HIPAA guidelines, and leverages clinical expertise to guide decisions and optimize patient outcomes. Qualified candidates must live in the Boston MA Regional Area to perform the daily travel responsibilities. For this role, there will be no weekends, no holidays, and no on-call work. Primary 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 quality review 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 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 medical chart review 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 review assessment for accuracy, respond to questions, or make 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 within Optum, 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, make referral) Required to travel within geographic territory (state of Massachusetts) at least 90% of the time (some weeks will require 100% travel as business needs dictate) and assist when 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: Must be a Registered Nurse (RN) with a current, active, unrestricted RN License in Massachusetts Must currently have OR be able 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 Medicaid Recent long-term care MMQ, MDS, staff development or management experience (in long-term care) Experience working within medical insurance and/or healthcare industries Experience analyzing inventory, researching, identifying, and resolving issues Experience with defining and managing processes within a team Experience trouble shooting issues for users within 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, concurrent authorization, and/or clinical appeal and guidance reviews Must live in the Boston MA Regional Area to conduct daily travel requirements Ability to travel within geographic territory (state of Massachusetts) at least 90% of the time (some weeks will require 100% travel as business needs dictate) and assist when needed throughout the state of Massachusetts for audits. (Audits will be conducted onsite) Must have reliable transportation and be able to provide proof of a valid, unrestricted Driver's License and current Auto Insurance 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 Proficiency with Microsoft Office Suite Proficient written and verbal skills 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 (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 to $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable. Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. 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. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, 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. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

Paid one on one training and education provided Empower, engage and train dialysis patients on peritoneal and home hemodialysis using state of the art training programs and equipment Primarily works in the clinic setting and conducts initial home visits with another staff member present Position functions as an onsite Patient Educator and Case Manager for patients with various shifts and work hours PURPOSE AND SCOPE: The registered professional nurse Home Therapies RN CAP 1 is an entry level designation into the Clinical Advancement Program (CAP). This position is accountable and responsible for the provision and coordination of clinically competent care including assessment, planning, intervention and evaluation for an assigned group of patients. Assesses and manages patients' response to home dialysis training and treatment therapy by following prescribed predetermined protocols and communicates patient related issues to the physician as needed. As a member of the End Stage Kidney Disease (ESKD) health care team, this position participates in decision-making, teaching, leadership functions, and quality improvement activities that enhance patient care outcomes and facility operations. PRINCIPAL DUTIES AND RESPONSIBILITIES: All duties and responsibilities are expected to be performed in accordance with Fresenius Kidney Care policy, procedures, standards of nursing practice, state and federal regulations. Performs all essential functions under the direction of the Supervisor with guidance from the Educator, Preceptor or in collaboration with another Registered Nurse. Performs ongoing, systematic collection and analysis of dialysis data for assigned patients and documents in the patient medical record, makes adjustments or modifications to treatment plan as indicated and notifies Supervisor or physician as needed. Assesses, collaborates and documents patient/family's basic learning needs to provide initial and ongoing education to patients and family. Directs and provides, in collaboration with the patient, home care partner, direct and ancillary patient care staff, all aspects of the provision of safe and effective delivery of dialysis therapy to assigned patients. Administers medications as prescribed or in accordance with approved algorithm(s), and documents appropriate medical justification and effectiveness. Initiates or assists with emergency response measures. Serves as a resource for health care team, participates in staff training and orientation of new staff as assigned. Ensures correct laboratory collection, processing and shipping procedures are performed and reschedules missed or insufficient laboratory collections. Identifies expected outcomes, documents and updates the nursing assessment and plan of care for assigned patients through collaboration with the Interdisciplinary Team. Ensures patient awareness related to transplant and treatment modality options. Assists in the identification, evaluation, selection and education of Home Dialysis candidates and Home Partners. Performs assessment and identifies barriers of the Home Dialysis candidate's home environment and partner / family readiness and ability to perform dialysis treatments in the home. Trains Home Dialysis patients and / or Home Partners on the safe, effective operation and maintenance of all Home Dialysis equipment and treatment supplies through an organized and formal Home Dialysis Training Program. Required to complete CAP requirements to advance. Performs all other duties as assigned by Supervisor. PHYSICAL DEMANDS AND WORKING CONDITIONS: The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The position provides direct patient care that regularly involves heavy lifting, moving of equipment, patients and assisting with ambulation. Equipment aids and/or coworkers may provide assistance. This position requires frequent, prolonged periods of standing and the employee must be able to bend over. The employee may occasionally be required to move, with assistance, machines and equipment of up to 200 lbs., and may lift chemical and water solutions of up to 30 lbs. as high as 5 feet. The work environment is characteristic of a health care facility with air temperature control and moderate noise levels. May be exposed to infectious and contagious diseases/materials. Rotates coverage with other licensed home therapies staff as assigned to ensure reliable and adequate coverage. Position requires participation in on-call rotation, night, weekend, holiday or as defined by individual program needs. The position may require travel to training sites, other facilities or patient homes. May be asked to provide essential functions of this position in other locations including patient's home with the same physical demands and working conditions as described above. Day to day work includes desk work, computer work, interaction with patients, facility/hospital staff and physicians. SUPERVISION: Assigned oversight of LPNs/LVNs, RNs, Patient Care Technicians and Home Therapy Care Team Assistants as a Team Leader or designated Nurse in charge, after meeting all the following: Successful completion of all FKC education and training requirements for new employees. Must have a minimum of 12 months experience as a RN. Successful completion of 3 months experience as a RN in home peritoneal dialysis and / or hemodialysis. EDUCATION and LICENSURE: Graduate of an accredited School of Nursing. Current appropriate state licensure. Current or successful completion of CPR BLS Certification Must meet the practice requirements in the state in which he or she is employed. EXPERIENCE AND REQUIRED SKILLS: Entry level for RNs with less than 2 years of Nephrology Nursing experience as a Registered Nurse. Minimum of 1-year experience as a Registered Nurse (preferred) Home dialysis therapy experience (preferred). ACKNOWLEDGEMENT: I acknowledge that I have read and accepted this job description. I understand what is expected of me in this position, and I am able to perform the essential functions as outlined with or without reasonable accommodation. Furthermore, I understand that the duties and responsibilities listed in this job description are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or a logical assignment to the position. If I have any questions about duties and responsibilities not specified in this job description that I am asked to perform, I should discuss them with my immediate Supervisor or my Human Resources representative. Fresenius Medical Care maintains a drug-free workplace in accordance with applicable federal and state laws. EOE, disability/veterans

Paid one on one training and education provided Empower, engage and train dialysis patients on peritoneal and home hemodialysis using state of the art training programs and equipment Primarily works in the clinic setting and conducts initial home visits with another staff member present Position functions as an onsite Patient Educator and Case Manager for patients with various shifts and work hours PURPOSE AND SCOPE: The registered professional nurse Home Therapies RN CAP 1 is an entry level designation into the Clinical Advancement Program (CAP). This position is accountable and responsible for the provision and coordination of clinically competent care including assessment, planning, intervention and evaluation for an assigned group of patients. Assesses and manages patients' response to home dialysis training and treatment therapy by following prescribed predetermined protocols and communicates patient related issues to the physician as needed. As a member of the End Stage Kidney Disease (ESKD) health care team, this position participates in decision-making, teaching, leadership functions, and quality improvement activities that enhance patient care outcomes and facility operations. PRINCIPAL DUTIES AND RESPONSIBILITIES: All duties and responsibilities are expected to be performed in accordance with Fresenius Kidney Care policy, procedures, standards of nursing practice, state and federal regulations. Performs all essential functions under the direction of the Supervisor with guidance from the Educator, Preceptor or in collaboration with another Registered Nurse. Performs ongoing, systematic collection and analysis of dialysis data for assigned patients and documents in the patient medical record, makes adjustments or modifications to treatment plan as indicated and notifies Supervisor or physician as needed. Assesses, collaborates and documents patient/family's basic learning needs to provide initial and ongoing education to patients and family. Directs and provides, in collaboration with the patient, home care partner, direct and ancillary patient care staff, all aspects of the provision of safe and effective delivery of dialysis therapy to assigned patients. Administers medications as prescribed or in accordance with approved algorithm(s), and documents appropriate medical justification and effectiveness. Initiates or assists with emergency response measures. Serves as a resource for health care team, participates in staff training and orientation of new staff as assigned. Ensures correct laboratory collection, processing and shipping procedures are performed and reschedules missed or insufficient laboratory collections. Identifies expected outcomes, documents and updates the nursing assessment and plan of care for assigned patients through collaboration with the Interdisciplinary Team. Ensures patient awareness related to transplant and treatment modality options. Assists in the identification, evaluation, selection and education of Home Dialysis candidates and Home Partners. Performs assessment and identifies barriers of the Home Dialysis candidate's home environment and partner / family readiness and ability to perform dialysis treatments in the home. Trains Home Dialysis patients and / or Home Partners on the safe, effective operation and maintenance of all Home Dialysis equipment and treatment supplies through an organized and formal Home Dialysis Training Program. Required to complete CAP requirements to advance. Performs all other duties as assigned by Supervisor. PHYSICAL DEMANDS AND WORKING CONDITIONS: The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The position provides direct patient care that regularly involves heavy lifting, moving of equipment, patients and assisting with ambulation. Equipment aids and/or coworkers may provide assistance. This position requires frequent, prolonged periods of standing and the employee must be able to bend over. The employee may occasionally be required to move, with assistance, machines and equipment of up to 200 lbs., and may lift chemical and water solutions of up to 30 lbs. as high as 5 feet. The work environment is characteristic of a health care facility with air temperature control and moderate noise levels. May be exposed to infectious and contagious diseases/materials. Rotates coverage with other licensed home therapies staff as assigned to ensure reliable and adequate coverage. Position requires participation in on-call rotation, night, weekend, holiday or as defined by individual program needs. The position may require travel to training sites, other facilities or patient homes. May be asked to provide essential functions of this position in other locations including patient's home with the same physical demands and working conditions as described above. Day to day work includes desk work, computer work, interaction with patients, facility/hospital staff and physicians. SUPERVISION: Assigned oversight of LPNs/LVNs, RNs, Patient Care Technicians and Home Therapy Care Team Assistants as a Team Leader or designated Nurse in charge, after meeting all the following: Successful completion of all FKC education and training requirements for new employees. Must have a minimum of 12 months experience as a RN. Successful completion of 3 months experience as a RN in home peritoneal dialysis and / or hemodialysis. EDUCATION and LICENSURE: Graduate of an accredited School of Nursing. Current appropriate state licensure. Current or successful completion of CPR BLS Certification Must meet the practice requirements in the state in which he or she is employed. EXPERIENCE AND REQUIRED SKILLS: Entry level for RNs with less than 2 years of Nephrology Nursing experience as a Registered Nurse. Minimum of 1-year experience as a Registered Nurse (preferred) Home dialysis therapy experience (preferred). ACKNOWLEDGEMENT: I acknowledge that I have read and accepted this job description. I understand what is expected of me in this position, and I am able to perform the essential functions as outlined with or without reasonable accommodation. Furthermore, I understand that the duties and responsibilities listed in this job description are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or a logical assignment to the position. If I have any questions about duties and responsibilities not specified in this job description that I am asked to perform, I should discuss them with my immediate Supervisor or my Human Resources representative. Fresenius Medical Care maintains a drug-free workplace in accordance with applicable federal and state laws. EOE, disability/veterans