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Registered Nurse-Revenue Utilization Review
2 months ago
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
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