Nurse Consultant II

Summary

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 optimum 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. The Nurse Consultant II will be involved in research and development for policies and be a SME for those policies as needed. Incumbents must be independent and driven in decision making without having information clearly stated and comfortable using 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, as well as internal and external business partners, is often necessary to promote evidence-based medicine and wellness, provide education and coordination of health care benefits, and facilitate member access to care in a timely and cost-effective manner.

The Nurse Consultant II will ensure access to appropriate services across the healthcare continuum and maximize member benefits. Nurse Consultants at level II 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. The Nurse Consultant II will provide full principles of education and ongoing guidance necessary to implement policies and processes necessary to division operations and decision making as needed, and work with internal and external vendor partners across programs on internal processes and clinical reviews. Incumbent must be able to perform root cause analysis of trends, report out on findings and provide recommendations to address.

Duties

• 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 well as programs supported by delegated vendor partners, as indicated.
• 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.
• Provides direction and assistance to clinical support team regarding benefit approvals and denials.
• Notifies the team of participants needs including the need for special education, reminder calls, satisfaction survey, incentives, or any additional service needs according to specific program guidance.
• Works across the department coordinating tasks with departmental teams as needed to complete tasks or meet member needs.
• Collaborates with the GEHA Medical Director regarding complex benefit decisions, appropriateness of care, and medical necessity reviews per policies as needed.
• Collaborates with primary care physicians and other treating professionals to determine medical necessity as appropriate.
• Educates members about accessing services, in-network use, and evidence-based guidelines.
• Process benefit determinations according to company policies.
• Takes accountability for obtaining and maintaining all professional licenses. Including CEUs and other trainings.
• Facilitates appropriate use of resources and coordinates necessary services to improve health status and impact the cost of care.
• Monitors and evaluates member progress toward gap closure and alter course as indicated.
• Employs engagement techniques to build relationships with members.
• Encourages members to participate in their health care decisions and assists members with researching treatment options.
• Critically thinks to solve problems.
• Proactively identifies potential barriers for members and helps steer them to positive health outcomes.
• Reviews member claims history and identifies interventions/service opportunities /appropriate care coordination.
• Gathers data and information from various reliable sources to recommend and create desk level policies and workflows for process improvement and role clarification.
• Uses learning theories to develop curriculum and deliver content as needed.
• Maintains a clear understanding of Plan Benefits.
• Effectively communicates internally and externally using written, verbal and listening skills.