Overview

Summary

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.

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Duties

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.
  • Completes 4-6-month orientation to meet the complexity of working 40+ work drivers and documentation.
  • Multitasks, proficient organizational skills, and ability to work multiple work drives simultaneously.
  • Ability to complete 1000’s of encounters based on assigned workload and organizational needs.
  • Uses critical thinking to review complex medical records to transcribe a veteran’s clinical path and to authorized payers based on InterQual and Milliman guidelines.

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.

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Requirements

Conditions of Employment

  • All qualified candidates encouraged to apply. Open to U.S. Citizens but non-citizens may be appointed when it is not possible to recruit qualified citizens.
  • All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA.
  • Selective Service Registration is required for males born after 12/31/1959.
  • Must be proficient in written and spoken English.
  • You may be required to serve a probationary period.
  • Subject to background/security investigation.
  • Selected applicants will be required to complete an online onboarding process.
  • Must pass pre-employment physical examination.
  • Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
  • Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) – See “Additional Information” below for details.
  • Must complete VetPro Credentialing.

Qualifications

To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 02/02/2023.

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 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: Strong clinical background with 3-4 years nursing experience, 1-3 years relevant case management or utilization review experience, InterQual experience preferred, Case Management or Utilization Review certification preferred. Knowledge and skilled in applying CPT, ICD 10, and HCPCS coding. Able to collaborate effectively and communicate with all areas within the revenue cycle.


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 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 years of nursing practice/experience; OR a Master’s degree in nursing or related field with a BSN and approximately 1-2 years 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 years of nursing practice/experience; OR a Doctoral degree and approximately 2-3 years of nursing practice/experience.

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. 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.

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.

Additional information

This job opportunity announcement may be used to fill additional vacancies.

This position is in the Excepted Service and does not confer competitive status.

VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.

To ensure compliance with an applicable preliminary nationwide injunction, which may be supplemented, modified, or vacated, depending on the course of ongoing litigation, the Federal Government will take no action to implement or enforce the COVID-19 vaccination requirement pursuant to Executive Order 14043 on Requiring Coronavirus Disease 2019 Vaccination for Federal Employees. Therefore, to the extent a VA job announcement includes language requiring applicants to be fully vaccinated against COVID-19 pursuant to Executive Order 14043, that requirement does not currently apply to this Job Announcement. VA may request information regarding your vaccination status, if selected, for the purposes of implementing other workplace safety protocols, such as masking, physical distancing, testing, travel, and quarantine.

If you are unable to apply online or need to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application.

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VA FCCPAC Orlando 733

13800 Veterans Way

Orlando, FL 32814

US