***INTERNAL APPLICANTS ONLY***
Provides medical clinical advice and is primary clinical resource to the Special Investigation Unit (SIU). Collaborates with SIU staff to investigate health care fraud. Manages a variety of health care fraud cases, by providing medical opinions, advising SIU staff on proper documentation needed. Requesting and reviewing medical records to determine accuracy and appropriate level of care. Maintain records on case reviews in a legally appropriate manner for possible litigation. Serves as clinical advisor to OPM OIG, and other law enforcement entities on case investigations. Handles all pre-authorization and pre-certification issues on SIU providers. Assist unit with member, provider and GEHA workforce education on health care fraud detection. Reviews case leads from the anti-fraud software system, providing clinical opinions on possible fraudulent behavior or patterns.
• Provide clinical advice and assistance to the SIU staff, OPM OIG special agents and other law enforcement personnel, to evaluate potential health care fraud issues and ongoing investigations.
• Works with SIU Staff on ongoing fraud investigations, providing direction and assistance to Fraud Analysts and SIU Specialists. Reviews medical records related to case investigations.
• Collaborates with the GEHA Medical Director regarding complex fraud cases and possible benefit decisions and obtains medical approval of denials.
• Reviews and makes recommendations on case leads supplied by anti-fraud software. Will become proficient in using the software and developing leads for further case investigations by the fraud analysts.
• Researches new medical technologies and standards: reviews information from university hospital systems, the National Institutes of Health, and local community resources and approved websites.
• Works collaboratively with peers and management to identify department opportunities for improvement using member feedback, clinical or program experience, and available data. Actively supports initiatives specific to improvement of department outcomes.
• Performs other duties as assigned.
Requires a Bachelor’s degree, current RN license in good standing in state of residence and must be eligible for licensure in all 50 US states. Additional years of qualifying work experience may be considered in lieu of Bachelor’s degree.
• Requires one year of service as a GEHA Care Management Nurse Consultant I
• Requires two years of recent RN care management experience in a hospital or managed care setting, such as a health insurance environment.
• Requires at least three years of nursing experience in a clinical setting. Requires current knowledge of clinical standards of care and disease processes.
• Requires critical thinking skills, effective verbal and written communications skills to consult with physicians and providers, and demonstrated ability to negotiate costs.
• Requires basic computer skills and knowledge of medical information systems. Required to coordinate the demands of cost control and service responsiveness for members in catastrophic medical situations.
• Required to disclose all adverse actions imposed by any State Board of Nursing.
GEHA is an Equal Opportunity Employer. GEHA will not discriminate against employees or applicants because they have inquired about, discussed, or disclosed their compensation or the compensation of another employee or applicant.
Our company's corporate headquarters is located in Lee's Summit near Douglas Rd and I-470 with a total of five locations in the Kansas City metropolitan area.