Health Insurance Specialist

Summary

This position is located in the Department of Health & Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), Office of Program Operations and Local Engagement(OPOLE). As a Health Insurance Specialist, GS-0107-9/11/12, you will develop, evaluate and implement compliance, audit and oversight requirements, policies, operating procedures related to activities and processes involved with the monitoring and oversight of external CMS stakeholders.

Duties

Analyze data, policies, or program requirements to support decision-making and improve operational outcomes.
Develop, implement, and evaluate programs, processes, or initiatives aligned with organizational goals.
Prepare reports, briefings, and documentation for leadership and stakeholders.
Collaborate with internal and external partners to ensure effective program execution and compliance.

Requirements

Qualifications
ALL QUALIFICATION REQUIREMENTS MUST BE MET BY THE CLOSING DATE OF THIS ANNOUNCEMENT. Your resume (limited to no more than 2 pages) 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 being considered further. In order to qualify for the GS-09, 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-07 grade level in the Federal government, obtained in either the private or public sector, to include: 1) Researching and applying Medicare, Medicaid, Children's Health Insurance Program (CHIP), or Affordable Care Act (ACA) statutes, regulations, or sub-regulatory guidance, particularly related to Medicare institutional payment policy, to assist in supporting formal approval, denial, or compliance determinations under supervisory review; 2) Drafting technical documents to communicate findings and decisions to providers, contractors, or federal partners; AND 3) Reviewing provider applications, program data, or audit reports to identify potential compliance issues and prepare findings or recommendations for supervisory review.. - OR - Substitution of Education for Experience: You may substitute education for specialized experience at the GS-09 level by possessing 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 to the position being filled. - OR - Combination of Experience and Education: Only graduate education in excess of the amount required for the GS-07 grade level may be used to qualify applicants for positions at the grade GS-09. Therefore, only education in excess of one full year of graduate-level education may be used to combine education and experience. TRANSCRIPTS are required to verify satisfactory completion of the educational requirement related to substitution of education for experience and combination of experience and education. Please see "Required Documents" section below for what documentation is required at the time of application. In order to qualify for the GS-11, 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-09 grade level in the Federal government, obtained in either the private or public sector), to include: 1) Analyzing and applying Medicare, Medicaid, Children's Health Insurance Program (CHIP), or Affordable Care Act (ACA) statutes, regulations, or sub-regulatory guidance, particularly related to Medicare institutional payment policy, to develop formal approval, denial, or settlement determinations; 2) Preparing technical documents to communicate findings and decisions to providers, contractors, or federal partners; AND 3) Reviewing provider applications, audit findings, or claims data to assess compliance with federal health insurance program requirements and formulate resolution recommendations.. - OR - Substitution of Education for Experience: You may substitute education for specialized experience at the GS-11 level by possessing a Ph.D. or equivalent doctoral degree or 3 full years of progressively higher level graduate education leading to such a degree or equivalent doctoral degree or LL.M., if related to the position being filled. - OR - Combination of Experience and Education: Only graduate education in excess of the amount required for the GS-09 grade level may be used to qualify applicants for positions at the grade GS-11. Therefore, only education in excess of a master's or equivalent graduate degree, or 2 full years of progressively higher-level graduate education leading to such a degree, may be used to combine education and experience. TRANSCRIPTS are required to verify satisfactory completion of the educational requirement related to substitution of education for experience and combination of experience and education. Please see "Required Documents" section below for what documentation is required at the time of application. In order to qualify for the GS-12, 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-11 grade level in the Federal government, obtained in either the private or public sector, to include: 1) Applying Medicare, Medicaid, Children's Health Insurance Program (CHIP), or Affordable Care Act (ACA) statutes, regulations, or sub-regulatory guidance, particularly related to Medicare institutional payment policy, to make and defend formal approval, denial, or settlement determinations with minimal supervisory oversight. 2) Developing and finalizing authoritative technical documents to communicate legal and policy findings to providers, contractors, or federal partners, serving as a subject matter resource for less experienced staff; 3) Leading the review and analysis of provider applications, audit findings, or claims data to evaluate compliance with federal health insurance program requirements, identify systemic issues or trends, and formulate actionable resolution recommendations for management consideration. Substitution of Education for Experience: There is no substitution of education to meet the specialized experience requirement at the GS-12 grade level. Combination of Experience and Education: There is no combination of experience and education to meet the specialized experience requirement at the GS-12 grade level. Experience refers to both 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/13045357

Required Documents

To apply for this position, you must submit a complete Application Package which includes: 1. Resume showing relevant experience; cover letter optional. NOTE: As of September 27, 2025, federal agencies will only accept resumes that are two pages or less in length. Your resume must indicate your citizenship and whether you are registered with the Selective Service if you are a male born after December 31, 1959. Your resume must also list your work experience and education (if applicable), including the start and end dates (mm/yyyy) of each employment, along with the number of hours worked per week. For work in the Federal service, you must include the series and grade level for the position(s). For resume and application tips, visit: https://www.cms.gov/files/document/2026-required-documents.pdf IN DESCRIBING YOUR WORK EXPERIENCE AND/OR EDUCATION, PLEASE BE CLEAR AND SPECIFIC REGARDING YOUR EXPERIENCE OR EDUCATION. We strongly encourage applicants to utilize the USAJOBS resume builder in the creation of resumes. Determining length of general or specialized experience is dependent on the below information and failure to provide ALL information WILL result in a finding of ineligible. Official Position Title (include series and grade if Federal job) Duties (be specific in describing your duties) Employer's name and address Supervisor name and phone number Start and end dates in the month and year format (e.g. June 2007 to April 2008) Full-time or part-time status (include hours worked per week) Salary 2. CMS Required Documents (e.g., SF-50, DD-214, SF-15, etc.). Required documents may be necessary to be considered for this vacancy announcement. Failure to provide the required documentation WILL result in an ineligible rating OR non-consideration. 3. College Transcripts. Although this position does not require a degree, you may substitute college credit in whole or in part for experience at specified grade levels. You must submit a copy of your transcript at the time of application in order to substitute your education for the required experience. If you do not submit a transcript, your education will not be considered in determining your qualifications for the position. You may submit an unofficial transcript or a list of college courses completed, indicating course title, credit hours, and grades received. An official transcript is required if you are selected for the position. College Transcripts and Foreign Education: Applicants who have completed part or all of their education outside the U.S. must have their foreign education evaluated by an accredited organization to ensure that it is comparable to the education received in accredited educational institutions in the U.S. For a listing of services that can perform this evaluation, visit the National Association of Credential Evaluation Services website. This list, which may not be all-inclusive, is for informational purposes only and does not imply any endorsement of any specific agency. 4. Reasonable Accommodation (RA) Requests: If you believe you have a disability (i.e., physical or mental), covered by the Rehabilitation Act of 1973 as amended, that would interfere with completing the USA Hire Competency Based Assessments, you will be granted the opportunity to request a RA in your online application. Requests for RA for the USA Hire Competency-Based Assessments and appropriate supporting documentation for RA must be received prior to commencing the USA Hire Competency-Based Assessments. Decisions on requests for RA are made on a case-by-case basis. If you meet the minimum qualifications of the position, after notification of the adjudication of your request, you will receive an email invitation to complete the USA Hire Competency-Based Assessments, based on your adjudication decision. You must complete all assessments within 48 hours of receiving the URL to access the USA Hire Competency-Based Assessments if you received the link after the close of the announcement. To determine if you need an RA, please click here to review the Procedures for Requesting a Reasonable Accommodation for Online Assessments.