Lead Workers Compensation Claims Examiner

Department Of Labor Jacksonville , FL 32277

Posted 4 months ago

  • Duties

Help Duties Summary

This position is located in the U.S. Department of Labor, Office of Workers Compensation Program (OWCP), Division of Energy Employees Occupational Illness Compensation (DEEOIC), Branch of Medical Benefits Adjudication and Bill Processing Medical Benefits Adjudication Unit.

  • This position is inside the bargaining unit.

  • Relocation expenses will not be paid.

  • Additional vacancies may be filled using this announcement, if authorized.

Learn more about this agency

Responsibilities

There is only 1 position available and it may be filled at any of the locations below. Please apply for the location(s) that you are able and available to report to. Once your application is submitted, you will only be considered for that location(s). Final determination of work location is made by the agency.

Washington, DC - Salary $99,172 to $128,920

Jacksonville, FL - Salary $88,704 to $115,313

Denver, CO - Salary $96,856 to 125,910

Cleveland, OH - Salary $92,369 to $120,078

Seattle, WA - Salary $96,656 to $125,651

DUTIES:

As a lead to medical benefits examiners, examines requests for compensable medical services and treatments for a full range of accepted occupational illnesses, to include, but not limited to, claims for Home Health Care, Hospice, and requests for Durable Medical Equipment.

Serves as the primary point of contact for all emergency or expedited medical requests for home health care, hospice, and durable medical equipment related to immediate care upon hospital discharge and cases with a terminal status. Assists the unit manager in assuring timely and efficient assignment of emergency or expedited requests to team members.

Examines evidence submitted in support of initial home health care claims, or other medical authorization requests, and determines if the submissions include sufficient factual medical evidence to support authorization, and takes appropriate development actions.

Evaluates and acts as a lead to team members in the evaluation of medical evidence, (e.g. medical documents, medical reports, diagnostic reports, etc., with assistance of Nurse

Consultants with or subsequent to the initial home health care claim or authorization request, and verifies that the claim or request involves an accepted medical illness/injury and identifies the presence of potential consequential illnesses.

Contacts claimants, representatives, medical officials, and/or providers to answer questions, resolve issues, and obtain corrected or supplemental documentation to support the claim/request (e.g. home health care, durable medical equipment, travel, etc.). As the lead, provides suppo

Ftand advice to team members if they have difficult cases.

Develops and assists team with developing questions and defining issues for physicians (with assistance of Nurse Consultants) in cases involving the need for supplemental medical information, resolution of conflicting medical documentation or medical authorization requests.

Initiates referrals to medical consultants, which includes preparing questions and a statement of accepted facts; reviews returned medical reports to ensure the medical consultant has answered all questions posed for a decision making. Provides technical advice and leadership to team members with difficult and/or complex questions.

EEOICP policies and procedures; reviews incoming threads, correspondence, or medical documentation from the Bill Processing Agent relating to home health care and other high priority request.

Reviews and takes appropriate actions on remanded cases from the Final Adjudication Branch (FAB). Based on the reason for the remand, further develops claim to account fqr any changes in circumstances or facts around benefits claimed, or changes in EEOICPA provisions. Acts as liaison with FAB Hearing Representatives, if difficult technical questions need to be answered.

Prepares written and oral presentations for meetings, outreach events or conferences whose attendees are medical providers, medical vendors, claimants, advocates, medical committees, employer and industry associations, labor unions and other parties interested in DEEOIC medical authorization processes and procedures.

Conducts research on complex medical authorization issues and collaborates with other staff, the

Nurse Consultants, and the Medical Director in developing and resolving difficult, and/or unusual requests for services. These collaborations may result in the formulation of recommended program policies, report preparation and/or written correspondence on findings to internal and external representatives.

Reviews surveillance and audit reports generated by the branch (Program Integrity Analysts), OIG, SOL, or other reporting entities, that identify potential duplication in services and areas of potential fraud. Identifies problems, determines relevance of information received and uses sound judgement to make appropriate decisions based on facts and provides recommendations to others for potential actions to reduce or eliminate potential waste, fraud or abuse.

As the Lead Medical Examiner, provides mentoring, training, direction, and guidance to the staff of Workers' Compensation Claims Examiners. This includes providing and evaluating assignments, insuring that work schedules are maintained, clarifying difficult and complex instructions and assignments for the staff, and resolves inter-team issues.

Travel Required

Occasional travel - 5%

Supervisory status

No

Promotion Potential
13 - This position has no further promotion potential.

  • Job family (Series)
    0991 Worker's Compensation Claims Examining

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  • Requirements

Help Requirements Conditions of Employment

  • Appointment to this position may require a background investigation.

  • Requires a probationary period if the requirement has not been met.

  • Must be at least 16 years old and a U.S. Citizen.

Applicants must meet time-in-grade, time-after-competitive-appointment and qualifications requirements within 30 calendar days after the closing date of the vacancy to be eligible for consideration for selection.

Federal Employees Please Note: Your SF-50 must include enough information to be able to determine that time-in-grade requirements have been met and reflects your position title, pay plan/series/grade, tenure and the type of appointment (i.e. competitive/excepted). In some cases you may need to submit more than one SF-50.

Reference the "Required Documents" section for additional requirements.

Qualifications

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

Applicants must have 52 weeks of specialized experience equivalent to at least the next lower grade level, GS-12, in the Federal Service.

Specialized experience includes the development, authorization and adjudication of medical benefits for home health care, medical equipment and medical services/treatment.

Education

There is no educational substitution for the GS-13 level.


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Lead Workers Compensation Claims Examiner

Department Of Labor