Remote Nurse Specialist, Health Plan Operations

Summary

Join Gravie as we improve the way people purchase and access healthcare through innovative health benefit solutions.

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

Responsibilities

• 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

Benefits

• Competitive pay
• Alternative medicine coverage
• Flexible PTO
• 16 weeks paid parental leave
• Paid holidays
• Cell phone reimbursement
• Education reimbursement
• 1 week of paid paw-ternity leave