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 Consolidated Patient Accounting Centers (CPAC) for revenue reimbursement. The RUR nurse applies advanced clinical knowledge - communication skills - and collaboration to promote improvements in patient care through systematic evaluation and analytical review of clinical information.

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/12838066
• 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
• Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• 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
• See VA Directive and Handbook 5019.

Duties

• 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
• 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
• Educates VA medical facility providers and other staff on revenue related topics
• 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
• Collaborates as needed for revenue cycle tasks with CPAC and VA medical facility staff - including but not limited to Facility Revenue - Billing - Insurance Verification - Veteran Services - Compliance - Providers - Health Information Management (HIM) - Utilization Management (UM) - and Community Care
• Completes 4-6 month orientation to meet the complexity of working 40+ work drivers and documentation
• Successfully completes Blackboard training (training designed to introduce staff to revenue operations and the staff role)
• Collaborates with third party payers on ordered level of care and treatment plans - conducting reviews on Service Connection (SC) - non-SC - Special Authority (SA) - precertification - prospective review - concurrent review - denial management - retrospective review - admission - and continued stay patients
• Tracks revenue charges and recovery to maintain and reach facility goals
• Reviews data analytics and metric expectations Prioritize workload according to department need and leadership direction The RUR RN participates on CPAC and/or facility committees - workgroups - performance improvement projects - and/or huddle boards
• 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 - 0730-1600 (Schedule may vary based on facility need) Compressed/Flexible: Compressed or Flexible schedule maybe available with supervisory approval - for highly qualified applicants - after full observation of performance - and upon completion of training requirements
• Telework: Not Authorized Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized