Staff Nurse (Utilization Review)

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