Nurse

Responsibilities of the RUR nurse include, but are not limited, to the following: 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 r