Legal Administrative Specialist (Insurance Benefits Claims Examiner)

Employer
USAJobs
Location
Washington, D.C
Posted
Oct 12, 2019
Closes
Oct 19, 2019
Function
Administrative
Hours
Full Time
Duties

Summary

As a Legal Administrative Specialist (Insurance Benefits Claims Examiner) at the GS-0901-9/11 with a full performance level of GS-11, you will be part of HI Federal Employee Insurance Ops,Office of Personnel Management. Responsible for reviewing health insurance disputes between enrollees and participating FEHB carriers ensuring enrollees receive benefits that OPM negotiated. Responding to general inquiries concerning disputed claim regulations, health insurance, and enrollment eligibility.
Learn more about this agency

Responsibilities

  • 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.
  • 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 a thorough case analysis of disputed health benefits claims.
  • Develop a written appeal response that is based on analysis of the contract language, FEHB Program regulations, policies and guidelines.


Travel Required

Not required

Supervisory status
No

Promotion Potential
11

Requirements

Conditions of Employment

  • Must be a U.S. Citizen or National
  • Males born after 12-31-59 must be registered for Selective Service
  • Suitable for Federal employment, determined by a background investigation
  • May be required to successfully complete a probationary period


Qualifications

For the GS 9/11: You must have education and/or specialized experience as follows:

For the GS-09: You must have specialized experience and/or directly related education to be minimally qualified for this position as follows:
  • One year of 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: a) Reviewing disputed health benefits claims and appeals; b) Reviewing basic information on claims requests to be sure all relevant information is listed; and c) Responding to inquiries on health benefits contracts and regulations.
OR
  • Master's or equivalent graduate degree or 2 full years of progressively higher level graduate education leading to such a degree in one or a combination of the following fields: Healthcare Administration, Health Policy, Business Administration, Management, or similar relevant degree, or LL.B. or J.D., if related. (Submit with your application)
OR
  • A combination of education and experience as described above.
For the GS-11: You must have specialized experience and/or directly related education to be minimally qualified for this position as follows:
  • One year of experience (equivalent in difficulty and complexity to the GS-09 grade level or comparable pay band in the Federal service) which demonstrates all of the following: a) Reviewing disputed health benefits claims and appeals; b) Researching and analyzing information containing medical records or documents to determine if the health insurance carrier's action is in accordance with the contract provisions and regulations of the Federal Employees Health Benefits (FEHB) Program; and c) Responding to inquiries on health benefits contracts and regulations.
OR
  • Ph.D. or equivalent doctoral degree or 3 full years of progressively higher level graduate education leading to such a degree in one or a combination of the following fields: Healthcare Administration, Health Policy, Business Administration, Management, or similar relevant degree, or LL.M., if related. (Submit with your application)
OR
  • A combination of education and experience as described above.
Merit promotion applicants must meet time-in-grade requirement as defined in 5 CFR 300, Subpart F.
  • One year at the GS-07 level is required to meet the time-in-grade requirements for the GS-09 level.
  • One year at the GS-09 level is required to meet the time-in-grade requirements for the GS-11 level.
You must meet all qualification and eligibility requirements by 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

This job does not have an education qualification requirement.

Additional information

Relocation expenses will not be paid. Current OPM employees may qualify as an exception.

The full performance level of this position is GS-11

This job opportunity announcement may be used to fill additional similar vacancies across OPM.

If you are unable to apply online or need to fax a document that you do not have in electronic form, view the following link for information regarding an Alternate Application: https://help.usastaffing.gov/Apply/index.php?title=Alternate_Application_Information

If you are a veteran and you are claiming 5-point veterans' preference, you must submit a copy of your DD-214 or other proof of eligibility.
If you are a veteran and you are claiming 10-point veterans' preference, you must also submit an SF-15, "Application for 10-Point Veterans' Preference" plus the proof required by that form. For more information on veterans' preference click here .

Males born after 12-31-59 must be registered or exempt from Selective Service (see https://www.sss.gov/Home/Registration ).

How You Will Be Evaluated

You will be evaluated for this job based on how well you meet the qualifications above.

For Category Rating: Once the application process is complete, a review of your resume and supporting documentation will be made and compared against your responses to the assessment questionnaire to determine if you are qualified for this job. If, after reviewing your resume and or supporting documentation, a determination is made that you have inflated your qualifications and or experience, you may lose consideration for this position. Please follow all instructions carefully. Errors or omissions may affect your eligibility. Qualified candidates will be assigned to one of the three quality categories: Qualified, Well Qualified, or Best Qualified. Qualified Category = Does not exceed the basic qualifications requirements described in the "Qualifications" section of this announcement. Well Qualified Category = Meets the basic qualifications requirements described in the "Qualifications" section of this announcement and demonstrates proficiency in the Critical Competencies defined below. (This category must be met to be considered under ICTAP procedures) Best Qualified Category = Meets the basic qualifications requirements described in the "Qualifications" section of this announcement and excels in the Critical Competencies defined below. The category assignment is a measure of the degree in which your background matches the competencies required for this position.

Your qualifications will be evaluated on the following competencies (knowledge, skills, abilities and other characteristics):
  • Insurance
  • Knowledge of insurance industry practices
  • Oral Communication
  • Research
  • Written Communication


The Category Rating Process does not add veterans' preference points or apply the "rule of three," but protects the rights of veterans by placing them ahead of non-preference eligible within each category. Preference eligibles who meet the minimum qualification requirements and have a compensable service-connected disability of at least 10 percent or higher will be listed in the highest quality category (except in the case of scientific or professional positions at the GS-09 level or higher).

Career Transition Assistance Programs: These programs apply to employees who have been involuntarily separated from a Federal service position within the competitive service or Federal service employees whose positions have been deemed surplus or no longer needed. To receive selection priority for this position, you must: 1) meet CTAP or ICTAP eligibility criteria; 2) be rated well-qualified for the position with a score of 80 or above based on the competencies listed above; and 3) submit the appropriate documentation to support your CTAP or ICTAP eligibility. For more information visit: http://www.opm.gov/rif/employee_guides/career_transition.asp .

Background checks and security clearance

Security clearance
Other

Drug test required
No

Position sensitivity and risk
Moderate Risk (MR)

Trust determination process
Credentialing , Suitability/Fitness

Required Documents

To apply for this position, you must provide a complete Application Package which includes:
  • Your Resume showing work schedule, hours worked per week, dates of employment and duties performed.
  • Other supporting documents:
    • Cover Letter, optional
    • College Transcript(s), if qualifying based on education
    • Veterans' Preference documentation, if applicable (e.g. DD-214 Member Copy 4 showing type of discharge/character of service; Current Active Duty members must submit a certification of expected discharge or release from active duty under honorable conditions dated within 120 days; SF-15 Form and related documentation; VA letter.)
    • Career Transition Assistance Program/Interagency Career Transition Assistance Program documentation, if applicable (e.g. Certification of Expected Separation, Reduction-In-Force Separation Notice, or Notice of Proposed Removal; SF-50 that documents the RIF separation action; and most recent performance appraisal.)
    • Worker's Compensation Separation: Agency certification of inability to place employee AND Notification of Separation OR Separation SF-50.
    • Disability Annuity Termination: Notification from OPM of disability annuity termination AND Separation SF-50 of the last position held.
    • Military Reserve or National Guard Technician Special Disability Retirement Annuity under 5 U.S.C. 8337(h) or 8456: Certification of special disability retirement annuity from a military department or National Guard Bureau AND Separation SF-50 of the last position held
  • Failure to submit any of the above mentioned required documents may result in loss of consideration due to an incomplete application package. It is your responsibility to ensure all required documents have been submitted.

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