Health Insurance Specialist (Claims Processing & Systems)

This position is located in the Department of Health & Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), Center for Medicare and Medicaid Innovation (CMMI), Business Services Group (BSG).

As a Health Insurance Specialist (Claims Processing & Systems), GS-0107-13, you will perform claims processing and systems work related to national health insurance programs, such as Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and private health insurance.

Duties

• Serve as an expert in the development, evaluation, and implementation of policies related to claims processing and system work.
• Perform Medicare claims processing, claims reviews, and the adjudication of provider claims to administer and monitor contracts with Medicare contractors.
• Review and provide analysis for claims/transactions processing activities, claims reviews, and program claims related processing systems used to make payments to providers/suppliers/insurers for the payment of covered services to beneficiaries.
• Develop and review healthcare policies and legislation in order to draft related policy documents, regulations, procedures and guidance to states.
• Prepare all forms of written correspondence regarding claims processing, and Medicare program issues to the public, Congressional staff, industry contacts, and State representatives.

Qualifications

ALL QUALIFICATION REQUIREMENTS MUST BE MET BY THE CLOSING DATE OF THIS ANNOUNCEMENT.

Your resume must include detailed information as it relates to the responsibilities and specialized experience for this position. Evidence of copying and pasting directly from the vacancy announcement without clearly documenting supplemental information to describe your experience will result in an ineligible rating. This will prevent you from receiving further consideration.

In order to qualify for the GS-13, you must meet the following: You must demonstrate in your resume at least one year (52 weeks) of qualifying specialized experience equivalent to the GS-12 grade level in the Federal government, obtained in either the private or public sector, to include:

1. Evaluate claims processing system functions related to quarterly release updates for Medicare Fee For Service claims; AND
2. Develop requirements to process claims from suppliers/providers/insurers; AND
3. Implement claims processing policy or related systems.

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.

Click the following link to view the occupational questionnaire: https://apply.usastaffing.gov/ViewQuestionnaire/12450538