NCCPAC Revenue Utilization Review (RUR) Registered Nurse

Department of Veterans Affairs • Middleton, WI

42d • Onsite

About The Position

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.

Requirements

• Licensure: 1 full and unrestricted license from any US State or territory

Responsibilities

• 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.

Benefits

• 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)

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Administration of Human Resource Programs
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees