Nurse Consultant

As a Nurse with the US Office of Personnel Management, Healthcare and Insurance, Federal Employees Insurance Operations, Disputed Claims Team, you will serve as a Nurse Consultant supporting medical disputed claims reviews, providing medical analysis and guidance, training staff, consulting on benefit issues, and supporting defensible decisions under the Federal Employees Health Benefits Program.

Qualifications:

Basic Education Requirement: All applicants must have a graduate or higher level degree, bachelors degree, associate degree, or diploma from an accredited professional nursing educational program. This education must have been accredited by the Commission on Collegiate Nursing Education,Council on Accreditation of Nurse Anesthesia Educational Programs, Accreditation Commission for Midwifery Education, or an accrediting body recognized by the U.S. Department of Education at the time the degree was obtained.

Licensure Requirement: Applicants must have passed the National Council Licensure Examination. In addition, they must possess a current, active, full, and unrestricted license or registration as a professional nurse from a State, the District of Columbia, the Commonwealth of Puerto Rico, or a territory of the United States.

Experience Requirements:

For the GS-13 Grade Level: Applicants must have one year of specialized experience equivalent to at least the GS-12 level in the Federal service, or equivalent, performing nursing, health insurance, medical claims, or health benefits review work that includes:

• Reviewing medical records, claims information, benefit provisions, or appeal materials to support decisions on health care services, coverage, or medical necessity;
• Applying medical terminology, coding information, health care procedures, or clinical standards to evaluate health benefit claims, appeals, or disputed coverage issues;
• Preparing written analyses, recommendations, correspondence, or case documentation involving medical claims, health benefits, or insurance coverage issues; and
• Providing technical guidance, training, or consultation to staff or stakeholders on medical claims review, health benefit interpretation, or appeal documentation requirements.

For the GS-14 Grade Level:

Applicants must have one year of specialized experience equivalent to at least the GS-13 level in the Federal service, or equivalent, performing nursing, health insurance, medical claims, or health benefits review work that includes:

• Independently evaluating medical records, claims information, benefit provisions, or appeal materials to develop recommendations on health care services, coverage, or medical necessity;
• Applying medical terminology, coding information, health care procedures, clinical standards, and insurance benefit provisions to resolve disputed claims or coverage issues;
• Preparing written medical analyses, recommendations, determinations, correspondence, or case documentation used to support benefit decisions or appeal responses;
• Providing technical guidance, training, or consultation to staff, managers, contractors, or stakeholders on medical claims review, health benefit interpretation, or appeal documentation requirements; and
• Identifying trends, issues, or process concerns in medical claims or disputed claims review and recommending changes to improve consistency, timeliness, or decision support.

You must meet all qualification and eligibility requirements by the closing date of this announcement.

Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religious; spiritual; community, student, social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

Responsibilities:

• Administers the medical disputed claims review process and provides medical guidance on disputed claims, policies, procedures, and documentation.
• Serves as a medical subject matter expert for claims examiners, specialists, leadership, and internal and external stakeholders.
• Coordinates independent medical consultant reviews and ensures medical decisions align with contract provisions, limitations, and exclusions.
• Reviews medical aspects of carrier benefit proposals and supports benefit negotiations with medical analysis and recommendations.
• Develops project plans and recommends process improvements to improve the quality and efficiency of disputed claims reviews.
• Trains Legal Administrative Specialists on appeal documentation, case review, medical issues, coding systems, and legal sufficiency considerations.
• Researches medical techniques, services, trends, and industry developments to support defensible medical-review analyses and benefit decisions.

Salary : $121,785