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Remote Optum Utilization Review Jobs in Massachusetts

Briljent

Clinical Domain Project Manager (PBM)

Boston, MA · Remote

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

... utilization review, clinical criteria configuration, and pharmacy system implementations, with ... This is a fully remote, full time engagement with an anticipated duration of ten months and an ...

UnitedHealth Group

Clinical Claim Review RN

Boston, MA · Remote

$29 - $52/hr

  • Retirement

Optum is a global organization that delivers care, aided by technology to help millions of people ... A background in utilization review for an insurance company or experience in case management

UnitedHealth Group

Clinical Claim Review RN

Boston, MA · Remote

  • Life

  • Retirement

Optum Insight is improving the flow of health data and information to create a more connected ... This position is Remote in Massachusetts. You will have the flexibility to work remotely* as you ...

UnitedHealth Group

IRR Clinical Claim Review RN

Plymouth, MA · Remote

$29 - $52/hr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

Optum is a global organization that delivers care, aided by technology, to help millions of people ... Utilization Management, pre-authorization, claim review, appeals review, or medical record review

UnitedHealth Group

Patient Care Coordinator

Worcester, MA · On-site +1

$17.50 - $23/hr

  • Medical

  • Retirement

Optum is a global organization that delivers care, aided by technology, to help millions of people ... Reviews and facilitates the updating of missing /outdated information in the patient record with ...

Dane Street, LLC

Group Health Operations Manager

Boston, MA · On-site +1

$75K - $93K/yr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

100% REMOTE JOB SUMMARY Oversee and ensure the overall profitability of the regional operations ... Utilization Review experience is required. JOB RELATED SKILLS/COMPETENCIES: * Present exceptional ...

Dane Street, LLC

Group Health Operations Manager

Boston, MA · Remote

$75K - $93K/yr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

100% REMOTE JOB SUMMARY Oversee and ensure the overall profitability of the regional operations ... Utilization Review experience is required. JOB RELATED SKILLS/COMPETENCIES: * Present exceptional ...

WellSense Health Plan

Medical Director

MA · On-site +1

$173K - $250K/yr

  • Medical

  • Dental

  • Vision

  • Retirement

  • PTO

... utilization trend management, quality, appeals and grievances, and pharmacy reviews. Our Investment in You: · Full-time remote work · Competitive salaries · Excellent benefits Key Functions ...

BMC HealthNet Plan

Medical Director

Boston, MA · On-site +1

$173K - $250K/yr

  • Medical

  • Dental

  • Vision

  • Retirement

  • PTO

... utilization trend management, quality, appeals and grievances, and pharmacy reviews. Our Investment in You: • Full-time remote work • Competitive salaries • Excellent benefits Key Functions ...

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Remote Optum Utilization Review information

What is the difference between Remote Optum Utilization Review vs Remote UnitedHealthcare Utilization Review?

AspectRemote Optum Utilization ReviewRemote UnitedHealthcare Utilization Review
CredentialsLicenses in relevant states, certifications like CCM or CRC often preferredLicenses in relevant states, certifications like CCM or CRC often preferred
Work EnvironmentRemote, home-based with flexible hoursRemote, home-based with flexible hours
Employer & IndustryOptum, healthcare services and utilization managementUnitedHealthcare, health insurance and utilization review

Both roles involve reviewing healthcare claims and authorizations remotely, requiring similar credentials and work environments. The main difference lies in the employer and specific healthcare focus: Optum specializes in healthcare services and utilization management, while UnitedHealthcare focuses on health insurance and claims review. Candidates often compare these roles to determine the best fit based on employer and industry specialization.

How does a Remote Optum Utilization Review nurse typically collaborate with multidisciplinary teams while working from home?

As a Remote Optum Utilization Review nurse, collaboration with multidisciplinary teams is primarily conducted through secure digital platforms, including video calls, emails, and electronic health record systems. You’ll regularly communicate with physicians, social workers, case managers, and other healthcare providers to review patient cases, coordinate care plans, and ensure compliance with clinical guidelines. Despite working remotely, maintaining clear and timely communication is essential for effective patient advocacy and decision-making. Team meetings and case discussions are scheduled virtually, fostering a supportive environment and ensuring you stay connected to the broader healthcare team.

What is a Remote Optum Utilization Review?

A Remote Optum Utilization Review position involves working for Optum, a healthcare services company, to evaluate medical records and determine the necessity and appropriateness of healthcare services. Employees in this role review clinical documentation to ensure that treatments meet established guidelines and help to manage healthcare costs while ensuring patient care is not compromised. The position is remote, meaning you can work from home or another location outside of a traditional office. Utilization review professionals often interact with healthcare providers, insurance companies, and patients, using their clinical expertise to make informed decisions.

What are the key skills and qualifications needed to thrive as a Remote Optum Utilization Review nurse?

To thrive as a Remote Optum Utilization Review Nurse, you need a current RN license, strong clinical judgment, knowledge of utilization management, and experience in case review or discharge planning. Proficiency with medical review software, electronic health records, and familiarity with UM guidelines such as InterQual or Milliman is typically required. Exceptional communication, attention to detail, and critical thinking are vital soft skills for effective collaboration and decision-making in a remote environment. These skills ensure accurate assessments, regulatory compliance, and optimal patient outcomes while maintaining efficiency in a virtual workflow.
What are the most commonly searched types of Optum Utilization Review jobs in Massachusetts? The most popular types of Optum Utilization Review jobs in Massachusetts are:
What are popular job titles related to Remote Optum Utilization Review jobs in Massachusetts? For Remote Optum Utilization Review jobs in Massachusetts, the most frequently searched job titles are:
What job categories do people searching Remote Optum Utilization Review jobs in Massachusetts look for? The top searched job categories for Remote Optum Utilization Review jobs in Massachusetts are:
What cities in Massachusetts are hiring for Remote Optum Utilization Review jobs? Cities in Massachusetts with the most Remote Optum Utilization Review job openings:
Remote Optum Utilization Review jobs near you
Infographic showing various Remote Optum Utilization Review job openings in Massachusetts as of July 2026, with employment types broken down into 100% Full Time. Highlights an 10% Hybrid, and 90% Remote job distribution.

Sr Utilization Management Nurse RN - Remote

UnitedHealth Group

Boston, MA • On-site, Remote

Full-time

Retirement

Posted 26 days ago

UnitedHealth Group rating

7.6

Company rating: 7.6 out of 10

Based on 146 frontline employees who took The Breakroom Quiz

186th of 887 rated healthcare providers

Job description

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization 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.
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.
If you live in Boston MA, you will have the flexibility to work remotely* as you take on some tough challenges.
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:
  • Registered Nurse (RN) with a current, active, unrestricted RN License in Massachusetts
  • 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

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
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 - $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.
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.

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