Physical Health Registered Nurse (Remote)

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

Work Schedule : Monday - Friday, 8 : 30am - 5pm with rotating weekend coverage.

GENERAL STATEMENT OF JOB

The Physical Health Registered Nurse is responsible for completing clinical reviews for appropriateness, medical necessity, and quality.

The Physical Health Registered Nurse applies standardized clinical review criteria to determine medical necessity for service authorization requests.

The Physical Health Registered Nurse refers service authorization requests to an appropriate physician peer reviewer when medical necessity criteria are not clearly met.

Reviews performed by the individual in this position may be pre-service, concurrent, or retrospective in nature. This position is part of a team of nurses, physicians, psychologists, pharmacists, and non-clinical associates who work closely to care for our members.

ESSENTIAL JOB FUNCTIONS

Process requests for authorization of services :

• Responsible for reviewing requests for authorization of services including inpatient hospital admissions, re-admissions, 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
• Perform 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, SKILL & 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 Licensed in the State of North Carolina or Nurse Licensure Compact (NLC) license.

RESIDENCY REQUIREMENTS : The person in this position is required to reside 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.