Physical Health Registered Nurse – Vaya

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🔥 0 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 determine medical necessity for service authorization requests • Refer requests to an appropriate physician peer reviewer when criteria are not clearly met • Perform pre-service, concurrent, and retrospective reviews • Process authorization requests for inpatient admissions, rehabilitation, skilled nursing, home care/home infusion, and outpatient or inpatient services • Document timely decisions and actions in the managed care information system (MCIS) • Meet contractual timelines for review activities • Communicate and interact with providers and internal/external partners to coordinate utilization-management activities • Communicate determinations to providers according to established processes • Participate in required staff meetings and complex case rounds • Perform discharge planning to support safe and timely enrollee discharges • Complete Inter-rater Reliability training, exams, and testing • Follow utilization-management workflow processes • Participate in a weekend and holiday coverage rotation • Perform other duties supporting utilization-management functions

🎯 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 and medical practice workflows • Knowledge of Vaya contracts with the North Carolina Department of Health and Human Services and other applicable contracts • Knowledge of federal and state confidentiality requirements • Knowledge of member and staff health and safety requirements • Knowledge of corporate compliance requirements and Vaya policies and procedures • Knowledge of project management principles • Clear, concise, and appropriate verbal, written, and electronic communication • Ability to present in large group settings • Ability to adapt to rapid changes and implement new initiatives • Computer literacy and familiarity with Microsoft Office software, Vaya’s Administrative Health Record, and/or Care Management Platform and Member Services and UM Platform • Strong problem-solving, decision-making, conflict-resolution, and critical-thinking skills • Ability to mentor, coach, and facilitate change and innovation • Ability to develop reporting mechanisms supporting and benchmarking quality initiatives • Must live in North Carolina, South Carolina, Georgia, Tennessee, Virginia, Maryland, or Florida

🏖️ Benefits

• Home-based, virtual work position • Salaried/exempt position • Not eligible for overtime compensation • Equal opportunity employer