Evaluates member health metrics and professional resources to inform, develop, select, implement, and sustain targeted UM/CM initiatives and programs.
Evaluates member level information regarding prospective Care Management or Utilization Management to determine whether intervention is necessary to meet the member's needs.
Refers member and providers to G.E.H.A resources and programs, as indicated.
Leverages a spectrum of hard and soft skills to collaborate with others across the service continuum to address member and provider daily and escalated needs.
Using effective engagement techniques, guides, assists and informs members when appropriate in a manner that maximizes their health plan benefits including but not limited to coordinating services, accessing in-network providers. closing gaps in care and altering health behavior.
Encourages members to participate in their health care decisions and assists members with researching treatment options.
Proactively identifies potential barriers, proposes and implements solutions.
Maintains a clear understanding of Plan Benefits.
Monitors and evaluates program effectiveness, tracks relevant metrics, and reports outcomes.
Performs in-depth and root cause analysis to identify barriers to care or member/provider experience.
Knowledge, Skills, and Abilities:
BSN and 4-6 years of relevant experience.
Active/Good standing RN license, including accountability for maintaining all requirements of licensing post hire, must be eligible to be licensed in all US states and territories.
Autonomously able to objectively analyze a variety of information and provide actionable insights for decision making and problem solving.
Skilled communicator with strong written, verbal, and active listening skills, effectively engaging through modern communication technologies.
Experience reviewing complex medical necessity appeals.
Clinical proficiency and expertise pertinent to role.
Case Management or Utilization Management experience.
Relevant certifications in case management or utilization management.
Experience in utilization management F.E.H.B. payor appeals.
Work-at-home requirements
Must have the ability to provide a non-cellular High Speed Internet Service such as Fiber, DSL, or cable Modems for a home office.
A minimum standard speed for optimal performance of 30x5 (30mpbs download x 5mpbs upload) is required.
Latency (ping) response time lower than 80 ms
Hotspots, satellite and wireless internet service is NOT allowed for this role.
A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
How we value you
Competitive pay/salary ranges
Incentive plan
Health/Vision/Dental benefits effective day one
401(k) retirement plan: company match - dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution
While this is a remote opportunity, at this time G.E.H.A does not hire employees from U.S. territories or the following states: Alaska, Hawaii, California, Washington, Oregon, Colorado, Wyoming, Montana, New York, Connecticut, Vermont, Pennsylvania, Maine.
Please note that the salary information is a general guideline only. G.E.H.A considers factors such as (but
Benefits
Health insuranceDental insuranceVision insurance401(k)Remote work options
Additional Information
Government Employees Health Association, Inc. (G.E.H.A) is a nonprofit member association that provides health and dental benefits that millions of federal employees and retirees, military retirees and their families have counted on since 1937. Offering one of the largest health and dental benefit provider networks available to federal employees in the United States, G.E.H.A empowers health and wellness by meeting its members where they are, when they need care.
G.E.H.A has one mission: To empower federal workers to be healthy and well.
The Nurse Consultant II provides professional nursing care within Clinical Operations, supporting members through assessment, planning, evaluation, and evidence-based practice to advance a positive member experience and ensure appropriate, cost-effective services across the care continuum. The role applies professional nursing, epidemiological, and analytical skills to understand, react to, and plan for current and emerging healthcare needs-both at the individual member level and across larger populations. Serving as a clinical advocate and liaison across departments and external partners, the Nurse Consultant II uses multiple systems to inform decisions, communicate effectively, and document care. The role may manage a large member population, evaluate and make recommendations on escalated clinical issues, and assess G.E.H.A's emerging health trends to recommend targeted improvements that support divisional and organizational objectives.
Geha · Worldwide