Registered Nurse- Revenue Utilization Review

About the role

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.

What you will do

• 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.
• 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.
• 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 7:00-3:30PM EST Compressed/Flexible: Not Authorized Telework: Authorized Upon Supervisory Approval- Limited telework available Virtual: This is not a virtual position.
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized PCS Appraised Value Offer (AVO): Not Authorized

Requirements

• U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• 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.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process.
• Acceptable form(s) of identification will be required to complete pre-employment requirements (***).
• Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Must pass pre-employment physical evaluation/examination.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• You may be required to serve a probationary period.
• Complete all application requirements detailed in the "Required Documents" section of this announcement.

How you will be evaluated

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC.

WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE.

Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

NOTE: Candidate's education, scope, and length of nursing practice (experience) will be considered in determining the grade and salary of the applicant selected. The recommended salary may be at any point in the range listed for this vacancy.

Experience as an RN will be evaluated to determine if the experience is of an acceptable level of quality with regard to the following five dimensions of nursing: Practice, Veteran/Patient Driven Care, Leadership, Professional Development, and Evidence/Based Practice/Research.

Each dimension of practice has criteria that demonstrate essential core competencies for VHA Nursing Personnel. Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social).

Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position.

It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.

Documents you must provide

• Long-form resume/Curriculum vitae (CV) SF-50/ Notification of Personnel Action The following documents are accepted and may be required if applicable to your eligibility and/or qualifications for this position.
• Cover Letter Long-form resume/Curriculum vitae (CV) Other (1) Performance Appraisal Professional Certification SF-50/ Notification of Personnel Action Transcript

What to expect next

Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met.

After the review is complete, a referral certificate(s) is issued, and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.

You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center. NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).

It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service.

HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities.

HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities.

HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.

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. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.

Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.