Nurse Consultant – Federal Health Benefits

About the role

The U.S. Office of Personnel Management is seeking a Nurse Consultant to support the Federal Employees Health Benefits Program. You will review disputed medical claims, provide expert medical analysis, and guide staff and stakeholders on benefit issues.

Key responsibilities

• Administer the medical disputed claims review process and offer guidance on policies, procedures, and documentation.
• Act as a medical subject‑matter expert for claims examiners, specialists, leadership, and internal/external stakeholders.
• Coordinate independent medical consultant reviews to ensure decisions align with contract provisions, limitations, and exclusions.
• Review medical aspects of carrier benefit proposals and support benefit negotiations with analysis and recommendations.
• Develop project plans and recommend process improvements to enhance quality and efficiency of claim reviews.
• Train Legal Administrative Specialists on appeal documentation, case review, medical issues, coding systems, and legal sufficiency.
• Research medical techniques, services, trends, and industry developments to support defensible decisions.

Required profile

• U.S. citizen or national; males born after 12‑31‑1959 must be registered for Selective Service.
• Graduate‑level nursing education from an accredited program recognized by the U.S. Department of Education.
• Pass the National Council Licensure Examination and hold an active, unrestricted RN license in a U.S. state, D.C., Puerto Rico, or U.S. territory.
• One year of specialized experience at the GS‑13 level or equivalent.
• Ability to obtain and maintain a federal background investigation clearance.

Required skills

• Medical coding
• Medical analysis