Legal Administrative Specialist (Claims Examiner)

Legal Administrative Specialist (Claims Examiner)
 

Summary

As a Legal Administrative Specialist (Insurance Benefits Claims Examiner), you will be part of Healthcare and Insurance, Office of Personnel Management. If selected, you will review health insurance disputes between enrollees and participating PSHB carriers to ensure Postal enrollees receive the benefits that OPM negotiated with carriers and respond to general inquiries concerning PSHB Program disputed claim regulations, health insurance coverage, and Federal enrollment eligibility.

This job is open to

Clarification from the agency

Please read this Public Notice in its entirety prior to submitting your application for consideration. You are applying to a resume database. Your resume and any documents submitted will be retained and may be used at any time during the open period of this Public Notice. U.S. Citizenship is REQUIRED. Promotion potential is contingent on the position to which appointed.

The public

U.S. Citizens, Nationals or those who owe allegiance to the U.S.

Duties

• Respond to Postal Service Health Benefits (PSHB) inquiries from Postal enrollees and/or their authorized representatives, including responses on appeals of disputed health benefit claims, benefits regulations, and other program related inquiries.
• Prepares written directives for the Contracting Officer's signature requiring carriers to provide benefits, as appropriate.
• Respond to general inquiries concerning disputed claim regulations, health insurance coverage, and Federal enrollment eligibility.
• 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 thorough case analysis on disputed health benefits claims.
• Develop a written appeal response that is based on analysis and PSHB Program benefit policies and guidelines.
• Track trends and systemic claim processing errors that surface from the disputed claim appeal process in order to provide recommendations to the Health Insurance Specialists for carrier to take corrective action or make contract language improvements.

RequirementsConditions 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
• This position is eligible for inclusion in the bargaining unit. The union that represents employees in this position is the American Federation of Government Employees (AFGE) Local 32.

Qualifications

THIS IS A PUBLIC NOTICE: This Notice is issued under Direct-Hire Authority (DHA) to recruit new talent for the positions listed below. This means that we can hire any qualified candidate, either from this notice or from any source.

We will refer qualified applicants to the selecting official for consideration. The organization's hiring need will determine the referral of additional applicants. Applicants will be notified about their application's status if referred or if we fill all vacancies.

For the GS-09 Grade Level: Applicants must meet at least ONE of the qualification requirements described under A, B, or C below:

[A] GRADUATE EDUCATION: A master's or equivalent graduate degree or two full years of progressively higher level graduate education leading to such a degree or LL.B or J.D., in Healthcare Administration, Health Policy, Business Administration, Management or other related degree.

[B] EXPERIENCE: You must have one year of specialized 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:

• reviewing disputed health benefits claims and appeals;
• responding to general inquiries concerning disputed claim regulations, health insurance coverage, and Federal enrollment eligibility; and
• researching contracts, law or regulation and obtaining additional information from outside sources, including the health benefit plan and providers.

[C] COMBINATION OF EDUCATION AND EXPERIENCE TO QUALIFY AT THIS LEVEL: You must have a combination of successfully completed post-high school education and experience may be used to meet total qualification requirements. To calculate, divide the number of semester hours earned (in excess of 18 semester hours) towards a graduate degree by 18. If your education is in quarter hours, convert to semester hours by multiplying the number of quarter hours earned by 2/3rds. Then divide the number of months of full-time experience by 12. If your experience was part-time, convert to full-time by dividing the number of hours worked per week by 40 then multiply by number of months. Add the two percentages. The total must equal at least 100 percent to qualify.

Work Schedule: These positions allow for multiple schedules. Work schedule will be determined at the time of selection.

Please note, there may or may not be actual/projected vacancies when you submit your application. Your resume and any supporting documentation will be retained with other applicants and reviewed as vacancies occur. You will not receive a notice regarding your application's status.
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

PLEASE NOTE: Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications (particularly positions with a positive education requirement). Therefore, applicants must report only attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education. Applicants can verify accreditation at the following website: http://www.ed.gov/admins/finaid/accred/index.html. All education claimed by applicants will be verified by the appointing agency accordingly. 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.

Additional information

This announcement will be used to fill vacancies through OPM-authorized Direct Hire Authority due to Critical Hiring Need/Severe Shortage of Candidates. Veteran preference and traditional rating/raking of applicants do not apply. For more information on OPM's authorization of Direct Hire Authority, please visit: https://www.opm.gov/policy-data-oversight/hiring-information/direct-hire-authority/

Relocation expenses will not be paid.

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: http://help.usastaffing.gov/Apply/index.php?title=Alternate_Application_Information

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. Click the following link for more information, https://help.usastaffing.gov/Apply/index.php?title=Alternate_Application_Information.