As a Legal Administrative Specialist (Insurance Benefits Claims Examiner), you will be part of Healthcare and Insurance, Office of Personnel Management. If selected, you will review health insurance disputes between enrollees and participating FEHB carriers to ensure Federal enrollees receive the benefits that OPM negotiated with carriers and respond to general inquiries concerning FEHB Program disputed claim regulations, health insurance coverage, and Federal enrollment eligibility.

Duties

Respond to Federal Employees Health Benefits (FEHB) inquiries from Federal enrollees and/or their authorized representatives, including responses on appeals of disputed health benefit claims, benefits regulations, and other program related inquiries. Prepares written directives for the Contracting Officer's signature requiring carriers to provide benefits, as appropriate. Respond to general inquiries concerning disputed claim regulations, health insurance coverage, and Federal enrollment eligibility. Perform research and obtain additional information from outside sources, including the health benefits Plan and providers. Consult with internal clinical advisors (e.g. nurse) to resolve disputed health benefits claims and develop responses to inquiries and correspondence. Conduct thorough case analysis on disputed health benefits claims. Develop a written appeal response that is based on analysis and FEHB Program benefit policies and guidelines. Track trends and systemic claim processing errors that surface from the disputed claim appeal process in order to provide recommendations to the Health Insurance Specialists for carrier to take corrective action or make contract language improvements.

Requirements

Qualifications

For the GS-07 Grade Level: Applicants must meet at least ONE of the qualification requirements described under A, B, or C below: [A] EDUCATION (Undergraduate and/or Graduate): SUPERIOR ACADEMIC ACHIEVEMENT PROVISIONS: A bachelor's degree in Healthcare Administration, Health Policy, Business Administration, Management or other related degree, plus at least one of the following superior academic achievement provisions: 1. A grade-point average (GPA) or B (3.0 or higher on a 4.0 scale) for all completed undergraduate courses, or courses completed in the last two years of undergraduate curriculum; -Or- 2. A grade-point average (GPA) of B+ (3.5 or higher on a 4.0 scale) for the required courses in your major field of study, or required courses in your major completed in the last two years of undergraduate study; -Or- 3. Rank in the upper one-third of your class in the college, university, or major subdivision at the time of application; -Or- 4. Elections to membership in a national scholastic honor society, other than freshman honor societies. Honor societies that have been approved are listed in the Association of College Honor Societies GRADUATE EDUCATION: One full year of graduate level study in Healthcare Administration, Health Policy, Business Administration, Management or other related degree. (An academic year of graduate education is considered to be the number of credit hours that the school attended has determined to represent one academic year of full-time study). [B] EXPERIENCE: You must have one year of specialized experience (equivalent in difficulty and complexity to the GS-05 grade level or comparable pay band in the Federal service) which demonstrates ALL of the following: reviewing disputed health benefits claims and appeals; reviewing basic information on claims requests to ensure all relevant information is listed; and searching records or material to develop, examine, adjust, or reconsider a claim settlement. [C] COMBINATION OF EDUCATION AND EXPERIENCE TO QUALIFY AT THIS LEVEL: You must have a combination of specialized experience and education beyond a bachelor's degree. The education and experience must be directly related to the work of the position to be filled. To calculate your percentage of graduate education, divide the number of graduate semester hours by 18. If your education is in quarter hours, convert to semester hours by multiplying the number of quarter hours earned by 2/3rds. To determine your percentage of qualifying experience, you must divide your total number of months of qualifying experience by the required number of months of experience. Add your percentages of education and experience. The two percentages must total at least 100%. For the GS-09 Grade Level: Applicants must meet at least ONE of the qualification requirements described under A, B, or C below: [A] GRADUATE EDUCATION: A master's or equivalent graduate degree or two full years of progressively higher level graduate education leading to such a degree or LL.B or J.D., in Healthcare Administration, Health Policy, Business Administration, Management or other related degree. [B] EXPERIENCE: You must have one year of specialized experience (equivalent in difficulty and complexity to the GS-07 grade level or comparable pay band in the Federal service) which demonstrates ALL of the following: reviewing disputed health benefits claims and appeals; responding to general inquiries concerning disputed claim regulations, health insurance coverage, and Federal enrollment eligibility; and researching contracts, law or regulation and obtaining additional information from outside sources, including the health benefit plan and providers. [C] COMBINATION OF EDUCATION AND EXPERIENCE TO QUALIFY AT THIS LEVEL: You must have a combination of successfully completed post-high school education and experience may be used to meet total qualification requirements. To calculate, divide the number of semester hours earned (in excess of 18 semester hours) towards a graduate degree by 18. If your education is in quarter hours, convert to semester hours by multiplying the number of quarter hours earned by 2/3rds. Then divide the number of months of full-time experience by 12. If your experience was part-time, convert to full-time by dividing the number of hours worked per week by 40 then multiply by number of months. Add the two percentages. The total must equal at least 100 percent to qualify. Merit promotion applicants must meet time-in-grade requirement as defined in 5 CFR 300, Subpart F. One year at the GS-05 level is required to meet the time-in-grade requirements for the GS-07 level. One year at the GS-07 level is required to meet the time-in-grade requirements for the GS-09 level. You must meet all qualification and eligibility requirements within 30 days of the closing date of this announcement. 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; religious; 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.

Education

IF YOU ARE USING YOUR EDUCATION TO QUALIFY: You MUST provide transcripts, official or unofficial transcripts are acceptable. All materials must be submitted by the closing date of the announcement.

PASS/FAIL COURSES: If more than 10 percent of your undergraduate course work (credit hours) was taken on a pass/fail basis, your claim of superior academic achievement must be based upon class standing or membership in an honor society.

GRADUATE EDUCATION: One academic year of graduate education is considered to be the number of credits hours that your graduate school has determined to represent one academic year of full-time study. Such study may have been performed on a full-time or part-time basis. If you cannot obtain your graduate school's definition of one year of graduate study, 18 semester hours (or 27 quarter hours) should be considered as satisfying the requirement for one year of full-time graduate study.

Contacts

• Address OPM Human Resources 1900 E St., NW Washington, DC 20415 US
• Name: OPM Human Resources
• Phone: 202-606-9321
• Email: [email protected]