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Clinical Review and Analysis RN

3 weeks ago

Durban, KwaZulu-Natal, South Africa VA Detroit Full time

Are you a dedicated and compassionate Registered Nurse looking for a challenging and rewarding role? We are seeking a talented Registered Nurse to join our team as a Revenue Utilization Review (RUR) Registered Nurse

About the Opportunity

As a RUR Registered Nurse, you will play a key role in ensuring the accurate and timely reimbursement of services provided to our nation's veterans. You will work closely with healthcare providers, third-party payers, and other stakeholders to identify and resolve complex clinical denials and ensure compliance with established guidelines.

This is a unique opportunity to utilize your skills and experience to make a meaningful impact on the revenue operations of the VA Detroit network.

Responsibilities
  • Review and analyze clinical information to ensure accuracy and completeness.
  • Identify and address complex clinical denials in collaboration with healthcare providers and third-party payers.
  • Develop and implement strategies to improve compliance with established guidelines.
  • Collaborate with RUR staff to provide feedback on performance improvement and utilization management initiatives.
  • Conduct precertification with third-party payers, including VA and Community Care as applicable.
  • Validate Service Connection (SC) Special Authority (SA) relatedness for revenue cases.
  • Manage clinical denials for revenue purposes.
  • Perform legal case-relatedness review for revenue billing purposes.
  • Provide education to VA medical facility providers and other staff on revenue-related topics.
  • Collaborate with CPAC and VA medical facility staff on revenue cycle tasks, including Facility Revenue, Billing, Insurance Verification, Veteran Services, Compliance, Providers, Health Information Management (HIM), Utilization Management (UM), and Community Care.
  • Collect, analyze, and report data related to revenue operations.
  • Collaborate 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.
What We Offer

We offer a comprehensive total rewards package that includes:

Competitive Salary

Paid Time Off: 50 days of paid time off per year, including 26 days of annual leave, 13 days of sick leave, and 11 paid federal holidays.

Retirement Benefits: Traditional federal pension and federal 401(k) with up to 5% contributions by VA.

Insurance: Federal health, vision, dental, term life, and long-term care insurance.

Licensure: Requirements vary based on location and position.

Work Schedule: Monday through Friday, 7:30am to 3:30pm, with potential for compressed or flexible schedules.

Requirements

To be considered for this position, you must meet the following requirements:

  • English Language Proficiency: In accordance with 38 U.S.C. 7403(f), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English.
  • Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE); OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program. Upon achievement of a State license, the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program. (Reference VA Handbook 5005, Appendix G6); OR In cases of graduates of foreign schools of professional nursing, possession of a current, full, active, and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program. Credit for foreign nursing education higher than associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD).
  • Current, full, active, and unrestricted registration as a graduate professional nurse in a State, Territory or Commonwealth (i.e., Puerto Rico) of the United States, or the District of Columbia. Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements, but do not possess the required licensure, may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.)
Additional Information

This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply.