Physical Health Registered Nurse – Remote

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🔥 15 minutes ago

🐊 Florida, North Carolina, +4 more states – Remote

🐊 Florida – Remote 🌲 North Carolina – Remote 🦀 Maryland – Remote 🌴 South Carolina – Remote 🎸 Tennessee – Remote ⚔️ Virginia – Remote

💵 $68k - $88.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Partners Health Management

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2012

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance • Health Care

Partners Health Management is a local management entity and managed care organization that focuses on providing essential mental health services, supports for individuals with intellectual and developmental disabilities, and substance use disorder services. Their mission is to assist members and their families in accessing the necessary care and resources to improve their overall well-being and integration into the community.

📋 Description

• Complete clinical reviews for appropriateness, medical necessity, and quality • Apply standardized clinical review criteria to service authorization requests • Refer requests to physician peer reviewers when medical necessity criteria are not clearly met • Review pre-service, concurrent, and retrospective requests • Process authorization requests for inpatient, rehabilitation, skilled nursing, home care/home infusion, outpatient, and inpatient services • Document timely decisions and actions in the managed care information system (MCIS) • Meet contractual timelines for review activities • Communicate with providers and internal and external partners to coordinate utilization management activities • Communicate determinations to providers according to established processes • Participate in staff meetings and complex case rounds • Perform discharge planning for safe and timely enrollee discharges • Complete utilization management workflow processes and other assigned UM duties • Participate in weekend and holiday coverage rotations

🎯 Requirements

• Associate Degree in Nursing required • Bachelor's Degree in Nursing preferred • Five years of clinical experience, preferably across the continuum of care • At least two years of acute care experience • Experience performing utilization management functions in a managed care setting • Active and unrestricted RN license in North Carolina or Nurse Licensure Compact (NLC) license • Thorough knowledge of primary care, behavioral health, and the healthcare system in North Carolina • Knowledge of Vaya Health's provider network, medical-practice workflows, contracts, policies, procedures, and organizational role • Knowledge of federal and state confidentiality requirements and member/staff health and safety requirements • Knowledge of project-management principles • Clear, concise verbal, written, and electronic communication skills • Ability to present in large-group settings and adapt to rapid changes • Ability to implement new initiatives • Computer literacy and proficiency with Microsoft Office, Vaya's Administrative Health Record, and/or Care Management Platform and Member Services and UM Platform • Problem-solving, decision-making, conflict-resolution, and critical-thinking skills • Ability to mentor, coach, facilitate change and innovation, and develop reporting mechanisms for quality initiatives • Ability to perform sedentary work, sit for extended periods, and lift up to 10 pounds • Close visual acuity, extensive reading, and repetitive hand, wrist, and finger motion required • Must live in North Carolina, South Carolina, Georgia, Tennessee, Virginia, Maryland, or Florida

🏖️ Benefits

• Home-based, virtual work position • Monday–Friday schedule, 8:30am–5:00pm EST • Equal opportunity employer