The RN Clinical Reviewer is a Registered Nurse, qualified by education and experience to provide direct support to the Payment Operations 104P in planning, designing, integrating, implementing, modifying, and evaluating the effectiveness of program components and/or services to improve the quality of patient care and the appropriateness and timeliness of services provided.

Duties

1. Provides leadership in the utilization of comprehensive knowledge of advanced nursing clinical practice and case management principles to assess appropriate level of care and to ensure compliance with established HSRM authorizations and guidelines resulting in approvals and/or denials for POM-OCC. 2. Conducts clinical reviews to interpret and evaluate data directly related to diagnosis, condition, and treatment to assure appropriate medical necessity, appropriate care coordination, and timely utilization POM-OCC services. Provides leadership in improving outcomes at the program or service level. 3. Applies knowledge of adult and geriatric disease entities and current accepted treatment modalities to establish conformance with criteria for expenditures. 4. Utilizes applicable technical skills in maintaining tracking methods for data retrieval and for ensuring accurate meaningful reporting system. 5. Demonstrates expertise in automated data processing systems and their application for communication and data management. Has skills to utilizes these systems to document clinical reviews for the clients. (e.g., VISTA, CPRS, JLV, VHA Intranet, ECAMS, HSRM, ARS, eCAT, PPMS, DataNet, Microsoft Word, Excel and Outlook) 6. Compiles data and clearly communicates care coordination outcome data systematically as requested for improvement in organizational processes. 7. Provides leadership in promoting excellence in customer service, internal/external by incorporating the VHA Core Values (integrity, commitment, advocacy, respect, excellence) into daily practice and performance. 8. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, or personal attributes. 9. Assures resources are applied in the most cost-effective manner while promoting quality patient care. Utilizes cost benefit analysis for purchased care requests and performs cost estimation for POM-OCC services, as applicable. 10. Identifies resource utilization patterns and changes that influence efficiency, quality of service, appropriateness of care, and minimization of inappropriate expenditures. Includes accurate avoidable day count. VA offers a comprehensive total rewards package: VA Nurse Total Rewards Pay: Competitive salary, regular salary increases, potential for performance awards Paid Time Off: 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Licensure: 1 full and unrestricted license from any US State or territory Work Schedule: Monday - Friday; Tour of Duty will be set based on organizational need. Compressed/Flexible: May be Authorized Telework: Authorized Virtual: This is a virtual position within 50 miles of one of the ten locations listed within this announcement. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required

Requirements

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. Basic 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 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). The approving official may authorize a waiver of the requirement for ACEN or CCNE accreditation of any degree in nursing provided the college or university has regional accreditation from an accrediting body recognized by the Department of Education at the time of the candidate's graduation and the composite qualifications of the applicant warrant such consideration. 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: 10 years nursing experience over all; 5 years of clinical experience in ED, ICU, Triage, case management, and care management. Grade Determinations: The following criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade: Nurse III - Master's degree in nursing or related field with BSN and approximately 2-3 years of nursing practice/experience; OR a Doctoral degree and approximately 2-3 years of nursing practice/experience. Note regarding MSN degrees: If your MSN was obtained via a Bridge Program that qualifies for professional nursing registration, a BSN is not required. Grade Determinations: The following criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade: Note regarding MSN degrees: If your MSN was obtained via a Bridge Program that qualifies for professional nursing registration, a BSN is not required. Reference: 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: Long periods of sitting in one location are required in completing transactions, using a computer with dual monitors as well as other standard office equipment.

Education

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.

Contacts

• Address VHA Servicing Human Resources Office - 2 2402 Wildwood Ave Suite 301 Sherwood, AR 72120 US
• Name: VHA National Recruitment Center
• Phone: (844)456-5208
• Email: [email protected]