Utilization Management Registered Nurse

Summary This position is located within the Nursing Service at the James A. Haley Veterans' Hospital in Tampa - Florida. The Utilization Management (UM) Nurse within the Quality Management Service Line. The incumbent provides clinical review - utilization oversight - and supports the organization's mission by ensuring Veterans receive care in the appropriate setting based on evidence‑based criteria. Qualifications 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) 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) Individuals graduating from 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) 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). NOTE: 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 (see online assessment) An Associate Degree (ADN) or Diploma in Nursing – no additional professional nursing required (Nurse I – Level I) An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I – Level 1 (Nurse I – Level II) An ADN or Diploma in Nursing AND 1 year of specialized nursing experience plus a BSN with no additional professional nursing experience required (Nurse I – Level III) A BSN with 2 years of professional nursing experience equivalent to Nurse I – Level 3 (Nurse III) Other combinations of BSN, MSN, and Doctoral degrees as outlined (see full details) Preferred Experience: Utilization Management (UM) in VA Healthcare plays a critical role in helping the VA manage and control healthcare costs by preventing the overuse, misuse, or underuse of medical services. By reducing unnecessary or redundant medical procedures and promoting cost‑effective treatments, UM enables the VA to manage its budget more effectively. Effective UM ensures the optimal use of limited healthcare resources— including hospital beds, medical tests, and medical equipment (such as CT and MRI scanners). Through careful review and guidance, UM advises on the appropriate level of care for each patient— helping to ensure Veterans receive the right care at the right time. This approach minimizes unnecessary delays and waste— allowing more Veterans to access the care they need. By prioritizing efficient and effective resource allocation— UM supports the VA’s mission to deliver high‑quality healthcare to Veterans— maximizing the impact of available resources and improving overall patient outcomes (Reference: Physical Requirements: This position requires visual acuity, keen hearing, clear distinctive speech, and manual dexterity. The work is primarily sedentary but may require periods of walking, standing, bending, and lifting light items such as papers, office materials, or medical records. The incumbent must be able to sit for prolonged periods while reviewing medical documentation and operating a computer. Occasional travel within the medical center and to affiliated sites may be required. The position demands the ability to concentrate, analyze information, and work effectively under pressure with multiple deadlines. The incumbent must demonstrate emotional and mental stability to perform the essential functions of the position and interact professionally with patients, staff, and interdisciplinary teams. Duties The Utilization Management Nurse functions within the Quality Management Service Line – performing clinical review, assessment, and coordination activities that support appropriate levels of care for Veterans The incumbent applies evidence‑based criteria to evaluate the medical necessity, timeliness, and efficiency of healthcare services Working collaboratively with interdisciplinary teams – the nurse helps ensure resources are used effectively and that Veterans receive high‑quality care aligned with VA policies, regulatory standards, and clinical guidelines This position supports continuous performance improvement, regulatory compliance, and optimal patient flow across the medical center The major duties of this position include: Conducting concurrent, retrospective, and prospective utilization reviews to determine the appropriate level of care and medical necessity across inpatient services; Applying standardized utilization management criteria and clinical judgment to assess treatment plans, diagnostic testing, and hospital admissions or continuations of stay; Monitoring for overuse, underuse, or misuse of services and communicating identified concerns to providers, care teams, and leadership for timely resolution; Coordinating with interdisciplinary teams to address barriers to care, promote timely transitions, and ensure Veterans receive the right care at the right time; Documenting UM findings and recommendations accurately and consistently in accordance with VA and facility guidelines; Preparing, analyzing, and presenting utilization data and trends to support quality improvement, performance measures, and organizational decision‑making; Supporting compliance with Joint Commission standards, VHA directives, and other regulatory requirements related to utilization management and resource stewardship; Participating in committees, workgroups, and initiatives related to UM performance improvement, patient flow, and quality management VA offers a comprehensive total rewards package: VA Nurse Total Rewards Pay – competitive salary, regular salary increases, and 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); Licensure – one full and unrestricted license from any U.S. State or territory; Work Schedule – Monday – Friday, 0730-1600 (flexibility may be required based on operational needs); Telework – Not Available; Virtual – This is not a virtual position; Relocation/Recruitment Incentives – Not Authorized; Permanent Change of Station (PCS) – Not Authorized #J-18808-Ljbffr Case Management Society of America (CMSA) ®