Remote RN: Utilization Management & Care Review

Vaya Health; North Carolina; Remote; USD 70,000 - 100,000; Full time

Job summary

Vaya Health seeks a Physical Health Registered Nurse to perform clinical reviews for authorization requests and medical necessity. You will reference standardized criteria and coordinate with physician peers when needed. This role is part of a multidisciplinary team focused on member care within a managed care framework.

The position requires R.N. licensure in NC, five years of clinical experience, including acute care and utilization management experience.

Qualifications

• Associate Degree in Nursing is required.
• Bachelor's Degree in Nursing is preferred.
• Five (5) years of clinical experience, with at least two years in acute care.
• Experience performing utilization management in a managed care setting.

Responsibilities

• Process requests for authorization of services.
• Document decisions in MCIS.
• Meet contractual timelines for review activities.
• Communicate with providers and internal/external partners.
• Utilize computer-based systems to support activities.
• Communicate determinations to providers.

Skills

Primary care knowledge

Behavioral health

Healthcare system NC

Communication skills

Microsoft Office

Care Management Platform

Education

Associate Degree in Nursing

Bachelor's Degree in Nursing preferred

Tools

Microsoft Office

Care Management Platform

Job description

Vaya Health seeks a Physical Health Registered Nurse to perform clinical reviews for authorization requests and medical necessity. You will reference standardized criteria and coordinate with physician peers when needed. This role is part of a multidisciplinary team focused on member care within a managed care framework.

The position requires R.N. licensure in NC, five years of clinical experience, including acute care and utilization management experience.