Nurse Consultant

<p>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.</p><h3>Major Duties</h3><p>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.</p><h3>Requirements</h3>Must be a U.S. Citizen or National Males born after 12-31-59 must be registered for Selective Service Suitable for Federal employment, determined by a background investigation May be required to successfully complete a probationary period Candidates will not be hired based on their race, sex, color, religion, or national origin Complete the initial online assessment and USAHire Assessment, if required You will be required to report to an OPM assigned office. This position is eligible for inclusion in the bargaining unit. The union that represents employees in this position is the American Federation of Government Employees (AFGE) Local 32.<h3>Education</h3>This position has a basic education requirement listed under the Qualifications section of this announcement.