The Revenue Utilization Review (RUR) nurse is an active member of the revenue cycle program and functions within the scope of the Consolidated Patient Account Center (CPAC) for revenue reimbursement.

Duties

Conduct clinical reviews for the purpose of pre-certification of admission; continued stay; and discharge reviews to obtain approval from third party payers (TPP) for services provided to Veterans. Use fundamental knowledge-based care and communication skills to perform clinical reviews and contact TPPs for authorization of services based on payer/policy requirements. This includes scheduled/non-scheduled inpatient and outpatient level of care; prescriptions (Rxs); Care in the Community; and/or durable medical equipment (DME). Advocate on behalf of the Veteran and conduct reviews requiring clinical input for sensitive diagnosis and special consent issues as per VHA regulations. Conduct special eligibility validation 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; ambulance; Care in the Community; and DME. Conduct clinical legal relatedness reviews for Regional Counsel TORT claims, No Fault, and Worker's Compensation cases to validate related care for reimbursement. Communicate with the facility revenue staff for Release of Information (ROI) documentation, and is compliant with VHA ROI requirements and Accounting of Disclosures. Provide feedback on appropriate clinics for precertification requirements based on TPP criteria. With assistance, conduct clinical appeals either oral or written as required by TPPs to overturn denials and increase reimbursement. This may include concurrent denials, retro- reviews/ appeals, or late load insurance. With assistance/guidance, respond to customer service issues regarding SC/SA care/treatment to validate billing appropriateness or need for billing exemption and/or Veteran refund. Customer service requests can be generated by Veterans or be automated requests when there is a change in Veteran eligibility. Identify performance improvement opportunities at the facility level. Seek opportunities to acquire knowledge and skills regarding RUR revenue process and TPP criteria and applies this knowledge to daily practice. 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 8:00a.m.-4:30p.m. Telework: Available - ONLY after successful completion of training and passing score (80% or higher) on quality reviews. 1-2 days per pay period. Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required

Requirements

Qualifications

Basic Requirements: English Language Proficiency. In accordance with 38 U.S.C. 7403(f), 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 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); OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program. Upon achievement of a State license, the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program. (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 to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program. Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD). 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. Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements, but do not possess the required licensure, may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification. Grade Determinations: The following Scope, Education and Dimension criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade. The Dimension requirements (Practice, Veteran/Patient Driven Care, Leadership, Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/12476853. Grade/Level Scope Education Nurse I, Level I Delivers fundamental, knowledge-based care to assigned clients while developing technical competencies. An Associate Degree (ADN) or Diploma in Nursing, with no additional professional nursing required. Nurse I, Level II Demonstrates integration of biopsychosocial concepts, cognitive skills and technically competent practice in providing care to clients with basic or complex. An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I, Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required. Nurse I, Level III Demonstrates proficiency in practice based on conscious and deliberate planning. Self-directed in goal setting for managing complex client situations. An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I, Level 2; OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I, Level 2; OR a Master's degree in nursing (MSN) and no additional professional nursing experience; OR a Master's degree in a *related field with a BSN and no additional professional nursing experience. Nurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others. A BSN with 2 years of professional nursing equivalent to Nurse I, Level 3; OR an MSN with one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I, Level 3; OR a Doctoral degree in Nursing with no professional nursing experience; OR a Doctoral degree in a *related field with a BSN with no additional professional nursing experience. Nurse III Executes position responsibilities that demonstrate leadership, experience and creative approaches to management of complex client care beyond the immediate practice setting. MSN and 2 years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Master's degree in *related field with BSN and two years of specialized nursing experience, one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III; OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III. *Note: Foreign education programs/degrees are not creditable as related degrees. Preferred Experience: Strong clinical background with 5 years nursing experience, 1-3 years relevant case management or utilization review experience. Ability to collaborate effectively and communicate with all areas within the revenue cycle. Previous experience in CPAC Revenue Utilization Review, InterQual/Milliman, and Case Management or Utilization Review certification preferred. Knowledge and skill in applying CPT, ICD 10, and HCPCS coding. 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: 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.

Contacts

• Address CPAC Mid South 1412 Hazelwood Dr Smyrna, TN 37167 US
• Name: Jessica Pinckney
• Phone: 843-739-5122
• Email: [email protected]