The Revenue Utilization Review (RUR) nurse is under the supervision of the Nurse Manager and ANM. The RUR nurse is an active member of the revenue cycle program and functions within the scope of the CPAC for revenue reimbursement. The RUR nurse applies advanced clinical knowledge, communication skills, and collaboration to promote improvements in patient care by maximizing the potential for the recovery of funds through systematic evaluation and analytical review of clinical information. **This is NOT a virtual position. You must live within or be willing to relocate within a commutable distance of the duty location.**To qualify for this position, applicants must meet all requirements by the closing date of this announcementBasic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency. In accordance with 38 U.S.C. 7402(d), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. Graduate of a school of professional nursing approved by the appropriate State-accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE). In cases of graduates of foreign schools of professional nursing, possession of current, full, active and unrestricted registration will meet the requirement of graduation from an approved school of professional nursing. OR The completion of coursework equivalent to a nursing degree in a MSN Bridge Program that qualifies for professional nursing registration constitutes the completion of an approved course of study of professional nursing. Students should submit the certificate of professional nursing to sit for the NCLEX to the VA along with a copy of the MSN transcript. (Reference VA Handbook 5005, Appendix G6) OR In cases of graduates of foreign schools of professional nursing, possession of a current, full, active and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing. Current, full, active, and unrestricted registration as a graduate professional nurse in a State, Territory or Commonwealth (i.e., Puerto Rico) of the United States, or the District of Columbia. Preferred Experience: At least five (5) years clinical nursing experience as a RN, managed care experience as a RN or case management experience as a RN. Knowledge of health insurance industry practices (pre-authorization of care, coordination of benefits and continued stay reviews, case management). Proficient and high level of comfort with computer software programs (such as MS Word, Excel, Outlook, Explorer); strong writing; strong analytical ability, health assessment ability to obtain descriptions about patient symptoms, how the symptoms developed, and a process to discover any associated physical findings to identify level of care needed.Grade Determinations: The following criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade: Nurse I Level I - An Associate Degree (ADN) or Diploma in Nursing, with no additional nursing practice/experience required. Nurse I Level II - An ADN or Diploma in Nursing and approximately 1 year of nursing practice/experience; OR an ADN or Diploma in Nursing and a bachelor's degree in a related field with no additional nursing practice/experience; OR a Bachelor's of Science in Nursing (BSN) with no additional nursing practice/experience. Nurse I Level III - An ADN or Diploma in Nursing and approximately 2-3 years of nursing practice/experience; OR an ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 1-2 years of nursing practice/experience; OR a BSN with approximately 1-2 years of nursing practice/experience; OR a Master's degree in nursing (MSN) or related field with a BSN and no additional nursing practice/experience. Nurse II - A BSN with approximately 2-3 years of nursing practice/experience; OR ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 2-3 year's of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 year's of nursing practice/experience; OR a Doctoral degree in nursing or meets basic requirements for appointment and has doctoral degree in a related field with no additional nursing practice/experience required. Nurse III - Master's degree in nursing or related field with BSN and approximately 2-3 year's of nursing practice/experience; OR a Doctoral degree in nursing or related field and approximately 2-3 year's of nursing practice/experience. The full performance level of this vacancy is VN III. The actual grade at which an applicant may be selected for this vacancy is in the range of VN I to VN III. The nursing board will determine the grade. References: VA Regulations, specifically VA Handbook 5005, Part II, Appendix G-6 Nurse Qualification Standard. This can be found in the local Human Resources Office. Physical Requirements: This position requires visual acuity, keen hearing, clear distinctive speech, and manual dexterity. This position requires potentially long periods of continued sitting and computer use and typing. The RUR nurse must be a mature, flexible, sensible individual capable of working effectively in stressful situations, able to shift priorities based on organizational needs and solve problems independently while utilizing critical thinking skills. ["The RUR nurse is under the supervision of a Nurse Manager, Assistant Nurse Manager, or designee, who provides the administrative and clinical supervision and general instruction, plans and assigns work, assigns time schedules, approves leave, performs quality reviews, coordinates internal control audits, and completes performance evaluations. The RUR nurse is responsible for being self-directed in the delivery of revenue reimbursement processes and under moderate supervision and instruction by the registered nurse manager. Responsibilities of the RUR nurse include, but are not limited, to the following:*Applies the nursing process to conduct clinical reviews for the purpose of pre-certification, admission, continued stay, and discharge reviews to obtain approval from third party payers (TPP).*Safeguards patient privacy and maintains confidentiality of all electronic and printed patient information according to HIPAA guidelines, the Privacy Act, and VHA policy.*Conducts special eligibility reviews including Service Connection (SC), Agent Orange, Combat Vet, and other special authority (SA) eligibilities as per regulations for third party revenue encounters including Inpatient/Outpatient level of care, RXs, Care in the Community, DME, and Ambulance.*Takes corrective action for identified deficiencies compliant with CPAC quality review, quality assurance, and internal control audit processes.*Conducts clinical legal relatedness review for Regional Counsel TORT Claims, No Fault, and Worker's Compensation cases to validate related care for reimbursement.*Conducts clinical appeals as required by the third party payers to overturn denials and increase reimbursement.*Responds to customer service issues regarding SC/SA care and treatment to validate billing appropriateness.*Completes unit specific documentation, based on CPAC RUR standards and policy.*Utilizes comprehensive knowledge of nursing clinical practice and case management principles to assess appropriate level of care and to ensure compliance with established Non-VA care authorizations and guidelines. Work Schedule: 7:30am-4:00pm Monday- Friday\nTelework: Not available.\nVirtual: This is NOT a virtual position.\nFunctional Statement: RUR RN #92173A, 67528A, 38122A, 18551A, 11666A\nBargaining Unit: 1276\nFinancial Disclosure Report: Not required"]
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.