About This Role
This Staff Nurse position focuses on utilization review, ensuring that services provided to Veterans receive approval from third-party payers. The role involves clinical reviews, patient advocacy, and collaboration with clinical and revenue staff.
Responsibilities
- Conduct pre-certification, admissions, concurrent, discharge, retrospective, and appeals/denial reviews to obtain approval from third-party payers for services provided to Veterans
- Perform clinical review in the Computerized Patient Record System (CPRS)
- Contact third-party payers for authorization of services
- Serve as a patient advocate and program liaison by conducting focused reviews requiring clinical input for sensitive diagnoses, special consent issues, service-connected (SC) and special eligibility validation, as well as clinical reviews for tort feasor and workers' compensation cases
- Review and conduct special eligibility validation reviews, to include SC, Agent Orange, Combat Vet, etc.
- Collaborate with clinical staff to provide education, feedback, and assistance regarding documentation of medical necessity, insurance review criteria, and SC issues; document results of the review
- Coordinate continuity of care with facility revenue staff as needed
- Collaborate with facility revenue staff for Release of Information (ROI) documentation; log disclosure of ROI; provide necessary information to ROI staff
- Actively participate in program development at the facility level and work to identify clinics that need to be added to the Huron High Dollar Clinic List
- Conduct SC reviews and assist with clinical reviews as directed by the Chief Business Office (CBO) (i.e., The Combat Vet Project)
- Provide support to other VA facilities
Requirements
- Documented skill in effective interpersonal relations and collaboration with interdisciplinary team members
- Documented skill in effective communication skills and professional behaviors that promote cooperation and teamwork with internal and external customers
- Documented skill in independent decision-making, sound clinical judgment, and critical thinking abilities
- Documented knowledge of quality improvement issues related to the utilization of resources
- Documented evidence of dependability
Preferred Education:
- Bachelor's of Science in Nursing (BSN)
Preferred Experience:
- At least one year of UR/UM Case Management experience
VA Nurse Qualifications:
- Nurse I Level I: An Associate Degree (ADN) or Diploma in Nursing; No experience
- Nurse I Level II: An ADN or Diploma in Nursing and approximately 1 year of experience, or an ADN or Diploma in Nursing and a Bachelor's degree in a related field and no experience; or a Bachelor's of Science in Nursing (BSN) and no experience
- Nurse I Level III: An ADN or Diploma in Nursing and approximately 2-3 years of experience, or an ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 1-2 years of experience; or a BSN with approximately 1-2 years of experience, or a Master's degree in nursing (MSN) or related field with a BSN and no experience
- Nurse II: A BSN with approximately 2-3 years of experience, or ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 2-3 years of experience, or a Master's degree in nursing or related field with a BSN and approximately 1-2 years of experience, or a Doctoral degree in nursing or meets basic requirements for appointment and has Doctoral degree in a related field with no experience
- Nurse III: Master's degree in nursing or related field with BSN and approximately 2-3 years of experience or Doctoral degree in nursing or related field and approximately 2-3 years of experience
- 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
Important Details
- Schedule: 8:00 AM to 4:30 PM, Monday-Friday (based on facility needs)
- Flex or Compressed Work Schedule: authorized after 6 months of successful training
- Telework: authorized after 6 months of successful training
Relocation Support
- Relocation expenses: not authorized
