MFP Registered Nurse

Vaya Health

Registered Nurse coordinating care, medication, and discharge planning for Vaya Health members transitioning from skilled nursing facilities in North Carolina. Collaborating with medical, behavioral health, and community providers.

Posted 8/5/2026full-timeRemote • Franklin • North Carolina • 🇺🇸 United StatesJuniorMid-Level💰 $68,033 - $88,443 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in nursing assessments, care coordination, and patient education for medically fragile adults, while effectively collaborating with healthcare teams and community resources to ensure comprehensive service delivery.

Highest-signal resume keywords

Registered Nurse License in North CarolinaTwo Years of RN ExperienceKnowledge of Minimum Data Set (MDS) SystemUnderstanding of Medicare and Medicaid BenefitsClinical Knowledge of Community Resources

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Nursing AssessmentMedication ReconciliationCare Plan DevelopmentData Analysis and ReportingHealth Literacy Assessment

Soft Skills

Strong Communication SkillsProblem-Solving Skills

Certifications & Qualifications

Associate Degree in Nursing

Industry Keywords

Skilled Nursing FacilitiesCommunity Service PlanningBehavioral Health ProvidersEmergency Medical Services (EMS)Dual Enrollment

About the role

Key responsibilities & impact

Perform nursing assessments and provide support for medically fragile adults and members with significant chronic health conditions, mental health, substance use, or co-occurring disorders transitioning from Skilled Nursing Facilities into the community
Monitor care and develop participant care and discharge plans
Provide patient and family education and assess health literacy
Perform medication reconciliation
Research, link, and review documentation and communicate by phone
Attend virtual treatment team and care team meetings
Coordinate community service planning and ensure service needs are addressed
Collect, enter, maintain, analyze, and report psychiatric and medical treatment data
Escalate high-risk health, safety, staff, or organizational scenarios to leadership
Coordinate services across the Vaya Health system and other healthcare and social determinant systems
Collaborate with Transition and Housing teams, Acute Response teams, hospital emergency departments, Skilled Nursing Facilities, inpatient discharge planning teams, primary and specialty care providers, behavioral health providers, home health and personal care providers, EMS, CAP/DA, PACE, and other community stakeholders
Identify gaps and barriers in services and intervene at individual or system level
Maintain timely and complete documentation of member-specific interactions
Provide Vaya staff training related to medical and MHDDSU
Serve as a consultant with virtual visit capabilities

Requirements

What you’ll need

Applicants must reside in North Carolina or within 40 miles of the North Carolina border
Associate Degree in Nursing required
Must be licensed as a Registered Nurse in North Carolina
Two years of experience as an RN required
Experience working in a skilled nursing facility preferred
Bachelor’s degree in Nursing preferred
Knowledge of the state plan, service availability, service definitions, network providers, community resources, and funding sources
Clinical knowledge and awareness of community resources
Knowledge of the Minimum Data Set (MDS) System
Understanding of Medicare and dual enrollment, including requirements for Durable Medical Equipment
Understanding of Medicare and Medicaid benefits transitions from Long-Term Care for medical care and pharmaceutical needs
Ability to liaise with Skilled Nursing Facilities, community hospitals, ACTT RNs, EMS, Home Health agencies, CAP/DA, PACE, and other medical teams
Strong communication and problem-solving skills
Ability to apply clinical and coordination skills across diverse and complex situations
Ability to perform sedentary work, sit for extended periods, and lift up to 10 pounds

Benefits

Comp & perks

Home-based, virtual position
Exempt status and not eligible for overtime compensation