Physical Health Registered Nurse (Remote)

Vaya Health; North Carolina; Remote; USD 60,000 - 80,000; Full time

Job summary

A health management organization is seeking a Physical Health Registered Nurse for a remote position. This role involves reviewing service authorization requests and collaborating with healthcare teams. Candidates must have an RN license in North Carolina, with significant clinical experience and strong communication skills. This exempt position does not offer overtime compensation and is open until filled.

Qualifications

• Five years of clinical experience, preferably across the continuum of care.
• At least two years of acute care experience.
• Experience in utilization management in a managed care setting.

Responsibilities

• Review service authorization requests for appropriateness and medical necessity.
• Communicate determinations to providers.
• Participate in staff meetings and complex case rounds.

Skills

Primary care knowledge

Behavioral health knowledge

Healthcare system knowledge in NC

Verbal communication skills

Written communication skills

Critical thinking

Conflict resolution

Mentoring skills

Education

Associate Degree in Nursing

Bachelor's Degree in Nursing

Tools

Microsoft Office

Managed Care Information System (MCIS)

Job description

Overview

LOCATION: Remote - this is a home-based, virtual position that operates from Monday through Friday, 8:30am-5:00pm EST. Vaya Health welcomes applications from NC, SC, GA, TN, VA, MD, and FL.

GENERAL STATEMENT OF JOB

The Physical Health Registered Nurse is responsible for completing clinical reviews for appropriateness, medical necessity, and quality. The RN applies standardized clinical review criteria to determine medical necessity for service authorization requests. The RN refers service authorization requests to an appropriate physician peer reviewer when medical necessity criteria are not clearly met. Reviews may be pre-service, concurrent, or retrospective. This position is part of a team of nurses, physicians, psychologists, pharmacists and non-clinical associates who work closely to care for our members.

The day-to-day operations of the Physical Health Utilization Management Department require coverage on weekends and holidays. The incumbent will be required to participate in a rotation to ensure coverage every day including weekends and holidays. The amount of work on scheduled weekends and holidays will be subject to change.

ESSENTIAL JOB FUNCTIONS

Process requests for authorization of services:

• Responsible for reviewing requests for authorization of services including inpatient hospital admissions, readmissions, inpatient rehabilitation services, skilled nursing admissions, home care / home infusion services, outpatient and/or inpatient services as designated.
• Documents timely decisions and actions taken within the managed care information system (MCIS).
• Meets contractual timelines for completion of review activities.
• Communicates and interacts with providers as well as internal and external partners to facilitate and coordinate the activities of the UM process.
• Utilizes technology (computer-based systems) and resources to support work activities appropriately.
• Communicates determinations to providers per established business process.

Supporting UM Functions:

• Actively participates in all required staff meetings and complex case rounds.
• Performs discharge planning to achieve safe and timely enrollee discharges from hospitals and facilities.
• Successfully completes Inter-rater Reliability (IRR) training, exams, and testing with at least an 80% passing rate or above thresholds established by management.
• Follows all UM workflow processes.

All other duties as assigned in support of UM functions.

KNOWLEDGE, SKILLS, & ABILITIES

This position requires a high degree of autonomy, professional relationships and organizational skills. Applicants with thorough knowledge of the following are prioritized:

• Primary care, behavioral health and healthcare system in NC;
• Vaya Health Provider Network;
• Medical practice workflows;
• Vaya contracts with the NC Department of Health and Human Services (NCDHHS) and other contracts for which Vaya is responsible;
• Vaya organizational purpose/role per federal and state statute, strategic plan, leadership and departmental roles, relationships and scope;
• Federal and state confidentiality requirements;
• Member and staff health & safety requirements;
• Corporate compliance requirements;
• Vaya Policies and Procedures;
• Project management principles.

Additional required skills and abilities include but are not limited to the following:

• Clear, concise and appropriate verbal, written and electronic communication;
• Ability to present in large group settings;
• Ability to adapt to rapid changes;
• Effectively implement new initiatives;
• Computer literacy and familiarity with Microsoft Office software as well as Vaya\'s Administrative Health Record and/or Care Management Platform, Vaya\'s Member Services and UM Platform.
• Strong conceptual skills, with knowledge and skill in problem-solving, decision-making, conflict resolutions, and critical thinking.
• Ability to mentor, coach and facilitate change and innovation.
• Ability to develop reporting mechanisms that will produce data needed to support and benchmark quality initiatives.

PHYSICAL REQUIREMENTS

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
• Mental concentration is required in all aspects of work.

QUALIFICATIONS & EDUCATION REQUIREMENTS

Associate Degree in Nursing required. Bachelor\'s Degree in Nursing preferred.

• Five (5) years of clinical experience preferably across the continuum of care with at least two years of acute care experience.
• Experience performing utilization management functions in a managed care setting.
• Proficient at using software programs such as Microsoft Office tools.

Licensure/Certification Required:

Active and unrestricted RN Licensure in the State of North Carolina or Nurse Licensure Compact (NLC) license.

RESIDENCY REQUIREMENTS The person in this position must live in NC, SC, GA, TN, VA, MD, or FL.

SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.

Vaya Health is an equal opportunity employer.