This position is in the Specialty Programs Department (SPD), Veteran and Family Member Programs (VFMP) Directorate, Office of Integrated Veteran Care (IVC), Veterans Health Administration (VHA), Department of Veterans Affairs (VA). This position reports to the Supervisory Program Analyst within SPD. The primary function of this position is to aid and lead in the daily examination, process, research, and auditing of healthcare claims for adjudication,

Duties

Duties include, but may not be limited to: Assigns, distributes, and balances daily workload within established limits and priorities and assures timely and accurate completion of work. Instructs employees in new procedures and provide ongoing guidance for problems/unusual cases. Provides training to new employees. Keeps supervisor informed of employee concerns and employees informed of management goals and objectives, implementation of changes, resolution of problems, and new or changed work methods. Performs the full range of technical duties of the staff and perform extensive audits of claims processed, manual processing of claims, and provider-researched cases by examiners. Examines, develops, and evaluates relevant documentation related to claims submitted for payment and audits improper payments and initiate appropriate recoupment actions. Provides direction and feedback in developing audit criteria, and reviews care providers' records to ensure that services billed to the program are documented and consistent with accepted standards. Performs research of discrepant claim information by relying on their independent, experienced judgment to discover information and make working assumptions for what transpired to ensure payments are within the program's general guidelines. Work Schedule: Monday-Friday, Between 6am and 430pm (Negotiable) Telework: VA supports the use of telework as a way to help attract and retain talented individuals in public service, increase worker productivity, and better prepare the agency to operate during emergencies. This position may be authorized for telework. Telework eligibility will be discussed during the interview process. Position Description/PD#: Lead Claims Examiner/PD91784A Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS):Not Authorized Financial Disclosure Report: Not required

Requirements

Qualifications

To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 09/14/2023. Time-In-Grade Requirement: Applicants who are current Federal employees and have held a GS grade any time in the past 52 weeks must also meet time-in-grade requirements by the closing date of this announcement. For a GS-08 position, you must have served 52 weeks at the GS-07. The grade may have been in any occupation, but must have been held in the Federal service. An SF-50 that shows your time-in-grade eligibility must be submitted with your application materials. If the most recent SF-50 has an effective date within the past year, it may not clearly demonstrate you possess one-year time-in-grade, as required by the announcement. In this instance, you must provide an additional SF-50 that clearly demonstrates one-year time-in-grade. Note: Time-In-Grade requirements also apply to former Federal employees applying for reinstatement as well as current employees applying for Veterans Employment Opportunities Act of 1998 (VEOA) appointment. You may qualify based on your experience as described below: Specialized Experience: You must have one year of specialized experience equivalent to at least the next lower grade GS-07 in the normal line of progression for the occupation in the organization. Examples of specialized experience would typically include, but are not limited to: Possess the examiner skills and knowledge needed to accomplish the functions of the position, including the coordination of benefits and application of the financial laws, regulations, manuals, procedures, and practices regarding entitlement to payment of all types of invoices/vouchers Research a variety of complicated transactions to analyze and resolve issues involving payment and denials of claims utilizing knowledge of automated healthcare claims processing systems Ability to calculate manually, process, and pay claims in conjunction with the redevelopment and reopening of claims and the event of computer payment system failures. Display thorough knowledge of the computer application software environment, including claims processing system, MS Office suite: Outlook, Word, PowerPoint, Excel, Teams, medical claim document repository, Attachment Retrieval System (ARS), Customer Relations Management (CRM) Make appropriate disposition on claims and determine entitlement to VA benefits using knowledge of VA regulations, policies, and procedures regarding treatment and eligibility requirements You will be rated on the following Competencies for this position: CompliancePlanning and EvaluatingProblem Solving Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience. Note: A full year of work is considered to be 35-40 hours of work per week. Part-time experience will be credited on the basis of time actually spent in appropriate activities. Applicants wishing to receive credit for such experience must indicate clearly the nature of their duties and responsibilities in each position and the number of hours a week spent in such employment. Physical Requirements: The work is primarily sedentary, with occasional requirements to walk around an office building to meet employees. Most work requirements involve using a computer and standard office automation equipment. The incumbent may need to stoop, bend, reach, or occasionally carry loads up to 20 pounds. Sitting in one location requires long periods in complete transactions, auditing, and research, using a computer with dual monitors and other standard office equipment. For more information on these qualification standards, please visit the United States Office of Personnel Management's website at https://www.opm.gov/policy-data-oversight/classification-qualifications/general-schedule-qualification-standards/.

Education

There is no educational substitution at this grade level.

Contacts

• Address Workforce Management - Community Care 120 SE 6th Street Suite 102 Topeka, KS 66603 US
• Name: VHA National Recruitment Center
• Phone: (844)456-5208
• Email: [email protected]