Health Insurance Specialist (Claims Processing and Systems)

Full Job Description

This position is located in the Department of Health & Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), Center for Medicare, Provider Billing Group Division of Supplier Claims Processing.

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

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-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) Evaluating claims processing activities or systems related to national health insurance programs to make recommendations for improvements; (2) Developing requirements to process claims from suppliers/providers/insurers; AND (3) Planning the implementation of 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/12876087 Major Duties:

• Serve as an expert in the development, evaluation, and implementation of policies related to claims processing and systems work and may serve as an ad hoc team/project leader.
• 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.
• Evaluate and analyze the impact of new of revised changes to legislation before the Congress pertaining to any CMS program.
• Develop, implement, and maintain operational requirements, including standard operating procedures, as well as databases to manage and analyze programmatic information such as routine and ad hoc report, deliverables, and programmatic documentation.
• Develop, review, and issue specifications, requirements, procedures, and instructional material to process claims from suppliers/providers/insurers.