Nurse Specialist - Health Plan Operations

6 days ago

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Gravie

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We partner with brokers across the nation to improve the way people purchase and access healthcare.

health insurance • health care • employer benefits • health • wellness

51 - 200

Description

• Be a key lead to collaborate and bridge the clinical team and health plan operations team to guide care for members and assist with applying benefits according to plan language. • Utilize your clinical experience in a collaborative way to assess appropriateness of treatment plans, apply evidenced based standards, and build SOPs where appropriate. • Monitor, evaluate, and coordinate options to facilitate appropriate benefits for members. • Gather and assess clinical information through medical records, case management, and other source information to apply appropriate clinical judgment for benefits coverage. • Experience with and a depth of understanding of medical policies so you can help create and standardize operations for medical policies at Gravie. • Deep understanding of Transition of Care, Continuity of Care, utilization management (UM), Prior Authorizations (PAs), Medical Necessity, appeals, claims reviews, gap exceptions, and application of benefits. • Lend expertise across the company to consult and provide administration support of UM, PAs, medical necessity, and appeal functions. • Review pre-certification lists for holistic Utilization Management. • Work with network Utilization Management/Case Management vendors to reduce errors and improve accuracy for both member and provider experience. • Use your experience and understanding of Fraud, Waste, and Abuse to perform internal audits of claims and suggest policies and procedures to reduce this risk. • Understand and suggest cost containment opportunities and strategies. • Think critically about plan language to clarify coverage and make the member journey as seamless as possible. • Bring together data and work directly with our Clinical Analytics and Reporting teams to give summaries of work being done and opportunities to intervene and improve. • Combine your experience of evidenced based practice with being innovative to drive new solutions for the best member experience. • Create effective relationships, listen, communicate and be a helpful team member across the organization.

Requirements

• Bachelor’s degree in nursing • Active RN or NP license in the state hired. • Experienced with health plan operations, preferably with a third-party administrator (TPA) or health plan. • 5+ years’ experience in nursing • 3+ years’ experience with UM and/or medical record reviews • Exceptional verbal and written communication skills, • Demonstrated customer service, communication, and organizational skills, • Ability to work independently, prioritize effectively, and make sound decisions,

Benefits

• alternative medicine coverage • flexible PTO • 16 weeks paid parental leave • paid holidays • cell phone reimbursement • education reimbursement • 1 week of paid paw-ternity leave