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 Specialty Supervisory Program Analyst within SPD.

Duties

The primary function of this position is to examine, process, research, and audit healthcare claim delivered to eligible beneficiaries by non-VA providers for adjudication, including determining and verifying entitlement to benefits, verifying post-entitlement actions regarding beneficiaries, and answering inquiries about benefits or procedures for filing claims. Major Duties Include (but are not limited to): Examines healthcare claims and other requests for payment of goods and services provided to beneficiaries by non-VA providers. Determines the amount due and process the necessary payment transactions for manually entered claims and carefully analyze claim submissions to determine payment correctness, including required certifications by authorized officials, compliance with contract provisions, price agreements, and other directive material. Analyzes desk procedures and policy documents for concurrence with observed claim corrections and report any anomalies to leadership and policy. Reviews guidelines and regulations to determine the specific provisions for healthcare claim submission. Enters payment information into a computerized healthcare claims payment processing system which applies to the claim type and program type Determines adequacy of information in support of a claim and determines whether a claim meets specific claims processing criteria for processing Evaluates missing requirements and reconstruct incomplete files to allow completion of claim processing and construct letters to providers and beneficiaries while auditing incoming claims. Promotion Potential: The selectee may be promoted to the full performance level without further competition when all regulatory, qualification, and performance requirements are met. Selection at a lower grade level does not guarantee promotion to the full performance level. Work Schedule: Monday-Friday, Between 6:00am-4:30pm 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. Virtual: This is not a virtual position. Position Description/PD#: Claims Examiner/PD26525A and PD26524A Relocation/Recruitment Incentives: Not Authorized Critical Skills Incentive (CSI): Not Approved 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, 11/29/2023. 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-07 position you must have served 52 weeks at the GS-06. For a GS-06 position you must have served 52 weeks at the GS-05.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: GS-07 Specialized Experience: You must have one year of specialized experience equivalent to at least the next lower grade GS-06 in the normal line of progression for the occupation in the organization. To be minimally qualified for this position at the GS-07 level, you must meet 4 of the 7 experiences listed below. Specialized experience is: Research a variety of complicated transactions to analyze and resolve issues involving payment and denials of claims utilizing automated healthcare claims processing systems, methods, procedures, and techniques. Possess thorough knowledge of the computer application software environment, including claims processing system, MS Office suite: Outlook, Word, PowerPoint, Excel, Teams, Ensemble DAPER, DATANET, Attachment Retrieval System (ARS), and CRM. Calculate and verify arithmetical computations and adjustments and transcribing facts and figures based on various supporting documents, forms, rates, pro-rations, potential back payments, and other unique factors and circumstances. Complete data entry transfer, calculations, and decision disposition utilizing working knowledge of complex types of claims regarding the processing of transactions based on statutes or policies. Make proper disposition of claims for compensation of medical care and to complete the required auditing, research, documentation, and letters, applying knowledge of medical terminology and the relationship between disease or injury. Functions as a technical authority for resolving a range of issues or problems using knowledge of interrelated program regulations and rulings covering a variety of types of enrollment and eligibility programs. Determines entitlement to VA benefits utilizing knowledge of claims processing operations, coordination of benefits, medical care cost recovery activities, and fraud waste and abuse incidents. GS-06 Specialized Experience: You must have one year of specialized experience equivalent to at least the next lower grade GS-05 in the normal line of progression for the occupation in the organization. To be minimally qualified for this position at the GS-06 level, you must meet 3 of the 5 experiences listed below. Specialized experience is: Assists in the research of a variety of complicated transactions to analyze and resolve issues involving payment and denials of claims utilizing automated healthcare claims processing systems, methods, procedures, and techniques. Possess knowledge of the computer application software environment, including claims processing system, MS Office suite: Outlook, Word, PowerPoint, Excel, Teams, Ensemble DAPER, DATANET, Attachment Retrieval System (ARS), and CRM. Calculate and verify arithmetical computations and adjustments and transcribing facts and figures based on various supporting documents, forms, rates, pro-rations, potential back payments, and other unique factors and circumstances. Complete data entry transfer, calculations, and decision disposition utilizing working knowledge of complex types of claims regarding the processing of transactions based on statutes or policies. Make proper disposition of claims for compensation of medical care and to complete the required auditing, research, documentation, and letters, applying knowledge of medical terminology and the relationship between disease or injury. You will be rated on the following Competencies for this position: Analytical ReasoningComplianceProblem 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]