Physical Health Registered Nurse (Remote)

Vaya Health

9d•Remote

About The Position

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. The day-to-day operations of the Physical Health Utilization Management Department require coverage on weekends and holidays. The incumbent in this position 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.

Requirements

Associate Degree in Nursing required.
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.
Active and unrestricted RN License in the State of North Carolina or Nurse Licensure Compact (NLC) license.
This position requires a high degree of autonomy, professional relationships and organizational skills.
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.

Nice To Haves

Bachelor’s Degree in Nursing preferred.
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 Heath 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.

Responsibilities

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.