This position is in the Beneficiary Claims Processing Unit, CHAMPVA program, 3.1 Network Development and Operations, Integrated External Networks, Integrated Veterans Care, Department of Veterans Affairs. The Claims Examiner reports to the Supervisor of the Beneficiary Claims Processing Unit. The primary function of the position is initial evaluation and processing of beneficiary submitted healthcare claims for payment.

Duties

PRINCIPAL DUTIES AND RESPONSIBILITIES: Responsible for the review and processing of claims received under the CHAMPVA Program Examine and evaluate relevant documentation related to the claims submitted for payment under the CHAMPVA Program. Prior to the processing of claims, the Claims examiner will review and research all submissions to determine all appropriate data is available to process the submission and to resolve other issues associated with the request for payment. Review all claims for duplicate detection, all forms of missing or discrepant data, medical audits such as for ambulance, dental, travel and durable medical equipment as they pertain to the beneficiaries' claims. Examines reimbursement of expenditures for accuracy, adequacy of documentation, or citations, compliance with regulations, and justification for CHAMPVA Family Member programs in a worldwide VA claims benefits program. Research and processing of CRM tasks for both beneficiary and provider claims. Analyze and resolve claims from appropriate suspense categories. Request to redevelop claims to issue proper payment after discrepant data has been identified and corrected. Reviews the claims that fail critical system edits and medical utilization audits based on artificial intelligence (AI) scenarios. System edits include duplicate detection, all forms of missing or discrepant data, medical audits such as for ambulance, dental, mental health services, durable medical equipment (DME), and medical care cost recovery (MCCR) situations, Other Health Insurance (OHI) questionable cases, etc. Identifies problems; determines accuracy and relevance of information; uses sound judgment to generate and evaluate alternatives, and to make recommendations. Makes sound, well-informed, and objective decisions; perceives the impact and implications of decisions; commits to action, even in uncertain situations, to accomplish organizational goals; causes change. 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 6:00a.m - 4:30p.m. or at the discretion of the supervisor and the needs of the agency 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/PD66123A and PD66122A Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required This position is in a bargaining unit

Requirements

Qualifications

To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 12/02/2024. 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-06 position you must have served 52 weeks at the GS-05. For a GS-07 position you must have served 52 weeks at the GS-06. 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-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. Examples of specialized experience would typically include, but are not limited to: Research to determine whether all required documentation is available, via a myriad of means to include, Paper submissions, DAPER, DATANET, Attachment Retrieval System (ARS) Datanet, ClamsXM, VistA query, and NPI (National Provider Identification) Research to obtain information not directly addressed in the regulations and guidelines for routine and unusual situations. 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. Research a variety of complicated transactions to analyze and resolve issues involving claim submission utilizing automated healthcare claims processing systems, methods, procedures, and techniques. 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. Examples of specialized experience would typically include, but are not limited to: Research claims for duplicate detection, all forms of missing or discrepant data, medical audits such as for ambulance, dental, travel and durable medical equipment as they pertain to beneficiaries claims.. Determine whether all required documentation is available, via a myriad of means to include, Paper submissions, DAPER, DATANET, Attachment Retrieval System (ARS) Datanet, ClamsXM, VistA query, and NPI (National Provider Identification) 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. 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 You will be rated on the following Competencies for this position: Attention to DetailDecision MakingProblem 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 VHA Central Office - Integrated Veteran Care 120 SE 6th Street Suite 102 Topeka, KS 66603 US
• Name: VHA National Recruitment Center
• Phone: (844)456-5208
• Email: [email protected]