This position is in the Veteran and Family Member Programs (VFMP) Directorate, Office of Integrated Veteran Care (OIVC), Veterans Health Administration (VHA). The incumbent serves as a Foreign Medical Program (FMP) Lead Claim Examiner and align under the FMP Supervisory Program Analyst in the Specialty Program Department (SPD). This position has the responsibility for the processing, quantitative and qualitative analysis of medical bills/invoices for the FMP disabled Veterans.

Duties

Assigns, distributes, and balances daily workload within established limits and priorities; assures timely and accurate completion of work. Instructs employees in new procedures and provides ongoing guidance for problem/unusual cases. Reviews and interprets regulatory criteria and applies those criteria to the work performed by those employees being led and answers employees' questions on policies, procedures, and directives. Provides on the job training to new employees. Responsible for the development and processing of claims received under the Foreign Medical Program; a health care benefits program for Veterans with VA rated service-connected conditions that are residing or traveling abroad FMP claims. Review claims for duplicate detection, all forms of missing or discrepant data, medical audits such as for dental, pharmacy, inpatient, outpatient, and durable medical equipment (DME) as they pertain to the Veteran's service-connected disability. Provides direction and feedback in the development of audit criteria and reviews records of providers of care to ensure that services billed to the program are documented and consistent with accepted medical care standards. Work Schedule: 6:00am- 4:30pm Monday- Friday 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#: Lead Claims Examiner/PD24475A 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, 01/05/2024. 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-09 position you must have served 52 weeks at the GS-08. 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 and/or education as described below: Specialized Experience: You must have one year of specialized experience equivalent to at least the next lower grade GS-08 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 advanced examiner skills to include claims processing operations, utilization and peer review programs, provider relations and reimbursement techniques, payment methodologies, coordination of benefits, medical care cost recovery activities, fraud, waste and abuse, and analysis of management data. Utilize knowledge of current editions of the International Classification of Diseases (ICD), 9th Revision, Clinical Modification (ICD-9- CM and ICD-10 CM) coding system, Current Procedural Terminology (CPT-4) coding system, Health Care Financing Administration Common Procedural Coding System (HCPCS) to assure reimbursement for claims, payments, and service-connected conditions. Determine details regarding payment and required payment amount to properly adjudicate a healthcare claim utilizing comprehensive knowledge of health insurance policy and plan types to include commercial, federal, and state plans such as Medicare, Tricare, Medicaid, BCBS, etc. Conduct research of Veterans history, claims, payments, and service-connected conditions utilizing specialized knowledge of Customer Relations Management (CRM), Treasury Check Information System (TCIS), Veterans Information Systems and Technology Architecture (VISTA), Veterans Benefit Management System (VBMS), and Daper. Apply knowledge of FMP vendors in order to create and edit vendors, ensuring that payments are sent to the correct foreign address. Education: Applicants may substitute education for the required experience. To qualify based on education for this grade level you must have a master's or equivalent graduate degree or 2 full years of progressively higher level graduate education leading to such a degree or LL.B. or J.D., if related... OR, Combination: Applicants may qualify on a combination of education and experience, the total percentage of experience at the required grade level compared to the specialized experience requirement, as well as the percentage of completed education compared to the educational requirement must equal at least 100 percent. You will be rated on the following Competencies for this position: Critical ThinkingEducation and TrainingManages Human ResourcesMedical InformationReading 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 in an office building to meet with 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 weighing up to 20 pounds. 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

A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

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]