Claims Examiner

Summary

This position is in the Civilian Health and Medical Program-VA (CHAMPVA) Review Unit (Review Unit), Veteran and Family Member Programs (VFMP) Directorate, Office of Integrated Veteran Care (IVC), Veterans Health Administration (VHA), Department of Veterans Affairs (VA). The position is organizationally aligned under the Chief, CHAMPVA.

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Overview

• Accepting applications

• Open & closing dates

06/24/2024 to 07/01/2024

• Salary

$60,362 - $78,468 per year

• Pay scale & grade

GS 8

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Location

20 vacancies in the following location:

• Denver, CO

• Remote job

No

• Telework eligible

Yes-as determined by the agency policy.

• Travel Required

Not required

• Relocation expenses reimbursed

No

• Appointment type

Permanent

• Work schedule

Full-time

• Service

Competitive

• Promotion potential

None

• Job family (Series)

0998 Claims Assistance And Examining

• Supervisory status

No

• Security clearance

Other

• Drug test

No

• Position sensitivity and risk

Non-sensitive (NS)/Low Risk

• Trust determination process

Credentialing

Suitability/Fitness

• Announcement number

CBZY-12453586-24-CRS

• Control number

796791300

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This job is open to

• Career transition (CTAP, ICTAP, RPL)

Federal employees who meet the definition of a "surplus" or "displaced" employee.

• Internal to an agency

Current federal employees of this agency.

Clarification from the agency

1st AOC: Career Transition (CTAP, RPL) Department of Veterans Affairs employees who meet the definition of "surplus" or "displaced" employees (see Additional Information section below); 2nd AOC: Current, permanent employees within the Veteran and Family Member Programs (VFMP) Department of the Integrated External Networks Division with the Office of Integrated Veteran Care (IVC) (as shown on your SF-50, Notification of Personnel Action, Block 22).

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Duties

The primary function of this position is to evaluate and process health care claims that are being corrected or reconsidered for payment. The position is responsible for requesting and/or obtaining the information required for reprocessing health care claims

Major duties include (but are not limited to):

• Evaluates and processes health care claims that are being corrected or reconsidered for payment.

• Responsible for the review and processing of claims received under the CHAMPVA Program, a health care benefits program for family members of veterans who are Permanently and Totally (P&T) disabled because of a VA adjudicated service-connected disability.

• Reviews guidelines and regulations to determine the specific provisions that are applicable to each healthcare claim submission.

• Responsible for resolving all discrepant data or aberrant claims situations generated by the claims processed by the center annually.

• Requests and/or obtains information required for reprocessing health care claims.

Work Schedule: Between 6:00 am - 4:30 pm, Monday-Friday

Telework: VA supports the use of telework as a way to help attract and retain talented individuals in public service, increase worker productivity, and better prepare the agency to operate during emergencies. This position may be authorized for telework. Telework eligibility will be discussed during the interview process.

Virtual: This is not a virtual position.

Remote: This is not a remote position.

Position Description/PD#: Claims Examiner/PD15754A

Relocation/Recruitment Incentives: Not Authorized

Critical Skills Incentive (CSI): Not Approved

Permanent Change of Station (PCS): Not Authorized.

Financial Disclosure Report: Not required

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Requirements

Conditions of Employment

• You must be a U.S. Citizen to apply for this job

• Selective Service Registration is required for males born after 12/31/1959

• You may be required to serve a probationary period

• Subject to background/security investigation

• Selected applicants will be required to complete an online onboarding process

• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP)

• Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details.

Qualifications

To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 07/01/2024.

Time-In-Grade Requirement: Applicants who are current Federal employees and have held a GS grade any time in the past 52 weeks must also meet time-in-grade requirements by the closing date of this announcement. For a GS-08 position you must have served 52 weeks at the GS-07. The grade may have been in any occupation, but must have been held in the Federal service. An SF-50 that shows your time-in-grade eligibility must be submitted with your application materials. If the most recent SF-50 has an effective date within the past year, it may not clearly demonstrate you possess one-year time-in-grade, as required by the announcement. In this instance, you must provide an additional SF-50 that clearly demonstrates one-year time-in-grade. Note: Time-In-Grade requirements also apply to former Federal employees applying for reinstatement as well as current employees applying for Veterans Employment Opportunities Act of 1998 (VEOA) appointment.

You may qualify based on your experience as described below:

• Specialized Experience: You must have one year of specialized experience equivalent to at least the next lower grade GS-07 in the normal line of progression for the occupation in the organization. To be minimally qualified for this position at the GS-08 level, you must meet 3 of the 5 experiences listed below. Specialized experience is:

1. Reviews, evaluates, and verifies all claims related to beneficiaries to make necessary corrections to claim transactions.

2. Examines a variety of routine and complex healthcare claims for payment of medical and ancillary care for eligible CHAMPVA Family Member program in a worldwide VA claims benefits program.

3. Inspects claims for duplicate detection, missing or discrepant data, and proper medical documentation.

4. Reviews and researches medical claims to determine all appropriate data is available to process or to resolve issues associated with the request for payment.

5. Verifies data points to include the beneficiary, vendor, diagnosis codes, billed amounts, and the input of the patient's responsibility after any other health insurance has made payment.

You will be rated on the following Competencies for this position:

• Insurance

• Problem Solving

• Technical Competence

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; religions; 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.

Note: A full year of work is considered to be 35-40 hours of work per week. Part-time experience will be credited on the basis of time actually spent in appropriate activities. Applicants wishing to receive credit for such experience must indicate clearly the nature of their duties and responsibilities in each position and the number of hours a week spent in such employment.

Physical Requirements: Work is performed in a fast paced and sometimes stressful professional office environment. Long periods of sitting in one location are required in completing transactions, using computer equipment. Work involves movement throughout the Claims Adjudication and Reimbursement Directorate and occasional trips to other Departments. Intense concentration is necessary in reviewing and researching claims submitted for payment along with work produced by CHAMPVA Claims Examiners.

For more information on these qualification standards, please visit the United States Office of Personnel Management's website at https://www.opm.gov/policy-data-oversight/classification-qualifications/general-schedule-qualification-standards/.

Education

There is no educational substitution at this grade level.

Additional information

The Career Transition Assistance Plan (CTAP) provides eligible displaced Department of Veterans Affairs (VA) competitive service employees with selection priority over other candidates for competitive service vacancies. To be qualified you must submit appropriate documentation (a copy of the agency notice, your most recent performance rating, and your most recent SF-50 noting current position, grade level, and duty location) and be found well-qualified for this vacancy. To be well-qualified: applicants must possess experience that exceeds the minimum qualifications of the position including all selective factors, and who are proficient in most of the required competencies of the job. Information about CTAP eligibility is on OPM's Career Transition Resources website at http://www.opm.gov/policy-data-oversight/workforce-restructuring/employee-guide-to-career-transition/.

During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions.

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

If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.

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• Benefits

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A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new window

Learn more about federal benefits.

Review our benefits

Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.

How You Will Be Evaluated

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

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE WILL NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE.

Narrative responses are not required at this time. If you are referred for consideration, you may be asked to submit additional job related information, which may include, but not limited to; responses to the knowledge, skills and abilities; completion of a work sample, and/or contact for an interview. Your resume and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect your rating or consideration for employment.

The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position.

For more information on the "Who may apply" eligibility requirements, please refer to the OHRM Status Candidates and Other Candidate Definitions document.

Placement Policy: The posting of this announcement does not obligate management to fill a vacancy or vacancies by promotion. The position may be filled by reassignment, change to lower grade, transfer, appointment, or reinstatement. Management may use any one or any combination of these methods to fill the position.

It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.