Physical Health Registered Nurse – Vaya

Partners Health Management

Physical Health Registered Nurse conducting utilization-management reviews for Vaya Health, a behavioral and physical health organization. Determining medical necessity, coordinating authorizations, and supporting safe member discharges.

Posted 8/5/2026full-timeRemote • Florida, Maryland, North Carolina, South Carolina, Tennessee, Virginia • 🇺🇸 United StatesMid-LevelSenior💰 $68,033 - $88,443 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical reviews, medical necessity determinations, and utilization management within a managed care setting. Proficient in communication, problem-solving, and compliance with healthcare regulations and standards.

Highest-signal resume keywords

Clinical Review ExpertiseUtilization Management FunctionsActive RN License in North CarolinaFive Years of Clinical ExperienceKnowledge of Vaya Health's Provider Network

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ReviewMedical Necessity DeterminationUtilization ManagementDischarge PlanningProject Management Principles

Soft Skills

Clear CommunicationProblem-SolvingDecision-MakingConflict ResolutionMentoring and Coaching

Tools & Technologies

Managed Care Information System (MCIS)Microsoft OfficeVaya's Administrative Health RecordCare Management PlatformMember Services and UM Platform

Certifications & Qualifications

Associate Degree in NursingActive RN License in North Carolina or NLC License

Industry Keywords

Healthcare System in North CarolinaFederal and State Confidentiality RequirementsCorporate Compliance RequirementsVaya Policies and ProceduresMember and Staff Health and Safety Requirements

About the role

Key responsibilities & impact

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

What you’ll need

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

Comp & perks

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