Vaya Health·North Carolina
The Physical Health Registered Nurse performs clinical reviews to determine the medical necessity and appropriateness of service authorization requests. They coordinate with providers and internal teams to facilitate utilization management processes and ensure safe enrollee discharges.
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.
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
All other duties as assigned in support of UM functions.
Knowledge, skills, & abilities
Physical requirements
Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
Mental concentration is required in all aspects of work.
Education & experience requirements
Associate Degree in Nursing required. Bachelor’s Degree in Nursing preferred.
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.
The person in this position must live in NC, SC, GA, TN, VA, MD, or FL.
Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.
Deadline for application: Open Until Filled
Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/ [https://www.vayahealth.com/about/careers/].
Vaya Health is an equal opportunity employer.
Market context
North Carolina nursing jobs often reflect steady demand in hospitals, clinics, and long-term care settings, especially for RNs who can provide age-appropriate care across patient populations. These roles are competitive because employers typically want an approved nursing-school graduate with a current North Carolina RN or Compact License and active AHA BLS certification. Review the AI-summarized requirements and benefits here to save research time, and confirm your license status and BLS renewal before applying.