Registered Nurse- Revenue Utilization Review

Veterans Health Administration • Asheville, NC

3d • Hybrid

About The Position

The Revenue Utilization Review (RUR) Nurse works under the supervision of the Nurse Manager and ANM as an active member of the revenue cycle program within the Consolidated Patient Accounting Centers (CPAC). The nurse applies advanced clinical knowledge, communication, and collaboration to evaluate clinical information and support improvements in patient care and revenue reimbursement.

The RUR Nurse conducts clinical reviews for precertification, admission, continued stay, and discharge to obtain third-party payer approval. The role includes eligibility and clinical relatedness reviews, appeals and denial management, customer service responses, staff education, documentation, collaboration across revenue-cycle teams, tracking charges and recovery, and reviewing analytics and metrics. The nurse completes a 4–6 month orientation and Blackboard training. The position participates in committees, workgroups, performance improvement projects, and huddle boards.

The schedule is Monday through Friday, 7:00 a.m.–3:30 p.m. EST. Compressed or flexible scheduling is not authorized. Limited telework may be available with supervisory approval; this is not a virtual position.

Requirements

• Graduate from an appropriately accredited school of professional nursing, or meet the stated qualifying nursing education provisions for bridge-program or foreign-school graduates.
• Hold current, full, active, and unrestricted professional nurse registration in a U.S. State, Territory, or Commonwealth, or the District of Columbia; the posting describes a Graduate Nurse Technician exception for eligible candidates pursuing licensure.
• Demonstrate basic written and spoken English proficiency.
• Meet the education and professional nursing experience requirements for the applicable VA Nurse grade and level.
• Be a U.S. citizen unless appointment of a qualified non-citizen is permitted under VA policy.
• Meet pre-employment conditions, including applicable drug testing, background/security investigation, onboarding and identification requirements, and a physical evaluation/examination.
• Participate in the seasonal influenza vaccination program.
• Meet the position’s physical requirements, including visual acuity, keen hearing, clear distinctive speech, and manual dexterity.
• Be able to sit for potentially long periods and use a computer and type.
• Be able to work effectively in stressful situations, shift priorities based on organizational needs, and solve problems independently using critical thinking.

Nice To Haves

• Three to four years of nursing experience.
• One to three years of relevant case-management or utilization-review experience.
• InterQual experience.
• Case Management or Utilization Review certification.
• Knowledge and skill in applying CPT, ICD-10, and HCPCS coding.
• Ability to collaborate effectively and communicate with all areas of the revenue cycle.

Responsibilities

• Conduct clinical reviews for precertification, admission, continued stay, and discharge to obtain approval from third-party payers.
• Protect patient privacy and maintain confidentiality of electronic and printed patient information in accordance with HIPAA, the Privacy Act, and VHA policy.
• Conduct special eligibility reviews, including Service Connection, Agent Orange, Combat Veteran, and other special-authority eligibility reviews for third-party revenue encounters.
• Conduct clinical relatedness reviews for Regional Counsel TORT claims, no-fault cases, and Workers’ Compensation cases to validate care for reimbursement.
• Conduct clinical appeals to overturn denials and increase reimbursement.
• Respond to customer service issues regarding Service Connection and special-authority care and treatment to validate billing appropriateness.
• Educate VA medical facility providers and staff on revenue-related topics.
• Complete unit-specific documentation according to CPAC RUR standards and policy.
• Assess appropriate levels of care and ensure compliance with non-VA care authorizations and guidelines using clinical practice and case-management knowledge.
• Collaborate with CPAC and VA facility revenue, billing, insurance verification, Veteran services, compliance, providers, Health Information Management, Utilization Management, and Community Care staff on revenue-cycle tasks.
• Collaborate with third-party payers on levels of care and treatment plans, and conduct eligibility, precertification, prospective, concurrent, denial-management, retrospective, admission, and continued-stay reviews.
• Track revenue charges and recovery to maintain and meet facility goals.
• Review data analytics and metric expectations.
• Prioritize workload according to department needs and leadership direction.
• Participate in CPAC and/or facility committees, workgroups, performance-improvement projects, and huddle boards.
• Complete a 4–6 month orientation and required Blackboard training.

Benefits

• Competitive salary, regular salary increases, and potential performance awards.
• 50 days of paid time off per year, including 26 days of annual leave, 13 days of sick leave, and 11 paid Federal holidays.
• Traditional federal pension with five-year vesting.
• Federal 401(k), with up to 5% in contributions by VA.
• Federal health, vision, dental, term-life, and long-term-care insurance; many federal insurance programs may be carried into retirement.
• One full and unrestricted license from any U.S. State or territory is accepted for licensure.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree