Nurse

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.

Qualifications

• Basic Requirements:
• English Language Proficiency: No person shall serve in direct patient care positions unless they are proficient in basic written and spoken English.
• Education: 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 that 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).
• Licensure: 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.)
• Grandfathering Provision: All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification.
• Grade Determinations: The following Scope, Education and Dimension criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade. The Dimension requirements (Practice, Veteran/Patient Driven Care, Leadership, Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/12965959.
• Physical Requirements: This position requires the ability to perform the essential functions of the job without restriction.