Nurse Consultant

Summary 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. Learn more about this agency Duties 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. Requirements Conditions of employment 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. 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. Education This position has a basic education requirement listed under the Qualifications section of this announcement. Additional information This announcement will be used to fill vacancies through OPM-authorized Direct Hire Authority due to Critical Hiring Need/Severe Shortage of Candidates. Veteran preference and traditional rating/raking of applicants do not apply. For more information on OPM's authorization of Direct Hire Authority, please visit: https://www.opm.gov/policy-data-oversight/hiring-information/direct-hire-authority/ Relocation expenses will not be paid. This job opportunity announcement may be used to fill additional similar vacancies across OPM. If you are unable to apply online and would like to request information about the Alternate Application process, please use the contact information at the bottom of this announcement. Reasonable Accommodation Requests: If you believe you have a disability (i.e., physical or mental), covered by the Rehabilitation Act of 1973 as amended and Americans with Disabilities Act 1990 as amended, that would interfere with completing the USA Hire Competency Based Assessments, you will be granted the opportunity to request a reasonable accommodation in your online application. Requests for Reasonable Accommodations for the USA Hire Competency Based Assessments and appropriate supporting documentation for Reasonable Accommodation must be received prior to starting the USA Hire Competency Based Assessments. Decisions on requests for Reasonable Accommodations are made on a case-by-case basis. If you meet the minimum qualifications of the position, after notification of the adjudication of your request, you will receive an email invitation to complete the USA Hire Competency Based Assessments, based on your adjudication decision. You must complete all assessments within 48 hours of receiving the URL to access the USA Hire Competency Based Assessments, if you received the link after the close of the announcement. To determine if you need a Reasonable Accommodation, please review the Procedures for Requesting a Reasonable Accommodation for Online Assessments here: https://help.usastaffing.gov/Apply/index.php?title=Reasonable_Accommodations_for_USA_Hire As a condition of employment for accepting this position, you may be required to serve a 1-year probationary period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider: - your performance and conduct; - the needs and interests of the agency; - whether your continued employment would advance organizational goals of the agency or the Government; and - whether your continued employment would advance the efficiency of the Federal service. Upon completion of your probationary period your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest. Expand Hide  additional information Candidates should be committed to improving the efficiency of the Federal government, passionate about the ideals of our American republic, and committed to upholding the rule of law and the United States Constitution. Benefits A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits. Review our benefits Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.