Nurse Consultant Ii Jobs

The Nurse Consultant II provides professional nursing care to our members through the execution of key duties within the discipline of the Clinical Operations division. Incumbents at level II support members through assessment, evaluation, planning, and evidence based research that promotes optuimum health care and service delivery.
Key responsibilities may include assessment of open gaps in care, education of the member on how to close those gaps, review of clinical history, and review of member's treatment plan against evidence based medicine. Incumbents must possess the ability to actively engage and influence the member to modify behaviors and health care decisions in support of improved health through direct member contact and/or clinical and/or plan policy development and management. Involved in research and development for policies and is a SME for those policies. Independent and driven in decision making without have information clearly stated. Uses clinical judgement when guidelines are not established. In some cases, this may require coordination with key external vendors. Additionally, collaboration and communication with the member’s family and health team is often necessary to promote evidence based medicine and wellness. The coordination of health care benefits, providing education, and facilitating member access to care in a timely and cost-effective manner.
The incumbents will ensure access to appropriate services across the healthcare continuum and maximize member benefits. The incumbents will serve as a clinical advocate for members and liaison within the division, among other departments and external health care teams. Use of systems to retrieve member information, document contacts, track member progress, and research evidence based practice is required.
Nurse Consultant II may manage a large assigned member population, provide ongoing guidance and delegate appropriate tasks. Provides full principles of education and ongoing guidance necessary to implement policies and processes necessary to division operations and decision making. Works with internal and external vendor partners across programs on internal processes and clinical reviews.

• May manage a participant caseload, to ensure that turnaround time and backlog are within team performance targets.
• Reviews member claims history and identifies opportunities. Initiates CM/MM services for members.
• Employs engagement techniques to build relationships with members.
• Encourages members to participate in their health care decisions and assists members with researching treatment options.
• Collaborates with the GEHA Medical Director regarding complex benefit decisions, appropriateness of care, and medical necessity reviews per policies.
• Takes accountability for obtaining and maintaining all professional licenses. Including CEUs and other trainings.
• Uses learning theories to develop curriculum and deliver content.
• Works across the department coordinating tasks with departmental teams as needed to complete tasks or meet member needs.
• Provides direction and assistance to clinical support team regarding benefit approvals and denials. Notifies Cost Utilization Specialist (CUS) of participants needs including the need for special education, reminder calls, satisfaction survey, incentives, or any additional service needs according to specific program guidance.
• Reviews member claims history and identifies interventions/service opportunities /appropriate care coordination.
• Monitors and evaluates member progress toward gap closure and alter course as indicated.
• Educates members about accessing services, in -network use, and evidence based guidelines.
• Collaborates with primary care physicians and other treating professionals to determine medical necessity as appropriate.
• Gathers data and information from various reliable sources to recommend and create desk level policies and workflows for process improvement and role clarification.
• Facilitates appropriate use of resources and coordinates necessary services to improve health status and impact the cost of care.
• Critically thinks to solve problems.
• Process benefit determinations according to company policies.
• Evaluates information regarding prospective Care Management (CM)/ Medical Management (MM) to determine whether intervention is necessary to meet the members needs.
• Refer to internal GEHA programs as indicated.
• Proactively identifies potential barriers for members and helps steer them to positive health outcomes.

• Five years of recent RN care management experience in a hospital or managed care setting, such as a health insurance environment or nursing experience in Fertility, Obstetrics, Labor, Postpartum, and NICU setting
• Bachelor’s degree, current RN license in good standing in state of residence and must be eligible for licensure in all 50 US states, additional years of qualifying work experience may be considered in lieu of Bachelor’s degree
• Required to coordinate the demands of cost control and service responsiveness for members in catastrophic medical situations
• Uses claims and care management software to document interactions and interventions with members, vendors, and providers. Maintains case information in the member’s clinical records to promote care coordination and accurate and timely claims payment. Identifies cost-savings activities and documents in care management software, including rationale for care
• Requires critical thinking skills, effective verbal and written communications skills to consult with physicians and providers and demonstrated ability to negotiate costs
• Requires the ability to use a personal computer, and knowledge of medical information systems
• Facilitates appropriate use of resources and coordinates necessary services to improve health status and impact the cost of care. Identifies member needs for and refers to appropriate internal and external programs, as appropriate. Redirects members and providers to in-network facilities when available. Negotiates rates for those services provided out of the network, as well as high dollar services provided in network, when appropriate
• Requires current knowledge of clinical standards of care and disease processes
• Incumbent is required to disclose all adverse actions imposed by any State Board of Nursing

• A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
• Hotspots, satellite and wireless internet service is NOT allowed for this role.
• Must have the ability to provide a non-cellular High Speed Internet Service such as Fiber, DSL, or cable Modems for a home office.
• Latency (ping) response time lower than 80 ms
• A minimum standard speed for optimal performance of 30x5 (30mpbs download x 5mpbs upload) is required.

• Company-provided Basic Life and AD&D
• Personal Community Enrichment Time
• Health/Vision/Dental benefits effective day one
• Competitive pay/salary ranges
• 401(k) retirement plan: company match – dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution
• Tuition Assistance Program
• Company-provided Short-Term & Long-Term Disability
• Incentive plan
• Robust employee well-being program
• Paid Time Off

The annual base salary range for this position is $70,139 - $98,261 USD.