Working Title: OPS NURSE CONSULTANT – 72901411
Salary: $22.00 per hour
Posting Closing Date: 09/18/2019
Nurse Consultant – OPS
Division of State Group Insurance
State of Florida Department of Management Services
This position is located in Tallahassee
20 hours/per week, worked during business hours (Monday – Friday 8 – 5 p.m.)
Position duration is for at least 4 months
The Florida Department of Management Services (DMS) is a customer-oriented agency responsible for managing the various business and workforce-related functions of state government. Under the direction of Governor Ron DeSantis and DMS’ Executive Leadership Team, the agency oversees the real estate, procurement, human resources, group insurance, retirement, technology, private prisons, fleet, and federal property assistance programs utilized throughout Florida’s state government. DMS is relied upon to establish, maintain and improve the business processes used by state employees to create a better, not bigger government. DMS facilitates the delivery of these programs and services and provides tools and training to bolster the efficiency and effectiveness of the state’s workforce. It is against this backdrop that DMS strives to demonstrate its motto, “We serve those who serve Florida.” Under the leadership of DMS Secretary Jonathan Satter, DMS’ employees embody four pillars on a daily basis: lead by example, serve with excellence, create efficiencies, and challenge the status quo.
The Department is seeking a licensed registered nurse. This OPS position will aid with conducting research for assigned level II clinical appeals; and researching claim disputes and issues benefit determination letters. This position is critical to ensure that the level II clinical appeals are researched and handled by an individual with the appropriate educational background and licensure. Also, this position requires a high degree of confidentiality, accuracy, and adherence to timeframes.
Specific responsibilities will include, but are not limited to, the following:
Researches assigned Level II clinical appeals and prepares agency action letters for approval by the director.
Researches claim disputes and issues benefit determination letters in accordance with applicable federal and state rules and benefit provisions.
Responds to routine requests for information and explains policies, procedures, and program information to eligible members; uses available resources (such as plan documents and websites) to educate members about covered services and benefits.
Clinical Consultation and Coordination:
Researches wellness benefits and incentives, best practices for disease management, clinical management and case management,
Coordinates with contracted health plans and the pharmacy benefits manager to implement approved clinical programs.
Provides cross functional support by performing other related duties as required due to the process-oriented, deadline driven functions of the unit. Provides prompt, professional and courteous customer service in response to all inquiries and requests for information received by the Division of State Group Insurance.
Knowledge, Skills and Abilities:
Knowledge of the State Employees’ PPO Plan, HMO plans, and the Prescription Drug Plan.
Understanding of clinical practices and procedures and medical records.
Knowledge of major medical insurance plan practices.
Outstanding oral and written communication abilities.
Ability to research and compile information and data from a variety of online and other sources.
Knowledge of state laws, rules, policies and procedures governing the State Group Insurance Program.
Knowledge of federal laws and regulations governing or affecting pretax benefit programs, including Internal Revenue Code Section 125, COBRA, Medicare, HIPAA, etc.
Ability to work independently.
Ability to establish and maintain effective working relationship with others.
Knowledge of People First procedures and system.
Proficient in Microsoft Office, Word, and Excel.
Outstanding customer service skills.
This position requires sedentary work and repetitive motion.
Accountability, Communication, Empowerment, Flexibility, Integrity, Respect, Teamwork
Registered Nurse, currently licensed in Florida.
Three to five years of nursing experience.
One year or more of professional work experience in the insurance industry.
Proficiency in Microsoft Office, Word, and Excel.
DMS is committed to successfully recruiting and onboarding talented and skilled individuals into its workforce. We recognize the extensive training, experience and transferrable skills that veterans and individuals with disabilities bring to the workforce. Veterans and individuals with disabilities are encouraged to contact our recruiter for guidance and answers to questions through the following provided email addresses.
An individual with a disability is qualified if he or she satisfies the skills, experience, and other job related requirements for a position and can perform the essential functions of the position with or without reasonable accommodation.
Candidates requiring a reasonable accommodation, as defined by the Americans with Disabilities Act, must contact the DMS Human Resources (HR) Office at (850) 488-2707. DMS requests applicants notify HR in advance to allow sufficient time to provide the accommodation.
Successful completion of background screening will be required for this position.
The State of Florida is an Equal Opportunity Employer/Affirmative Action Employer, and does not tolerate discrimination or violence in the workplace.
Candidates requiring a reasonable accommodation, as defined by the Americans with Disabilities Act, must notify the agency hiring authority and/or People First Service Center (1-866-663-4735). Notification to the hiring authority must be made in advance to allow sufficient time to provide the accommodation.
The State of Florida supports a Drug-Free workplace. All employees are subject to reasonable suspicion drug testing in accordance with Section 112.0455, F.S., Drug-Free Workplace Act.
Nearest Major Market: Tallahassee