This position is in the Beneficiary Claims Processing Unit, CHAMPVA program, 3.1 Network Development and Operations, Integrated External Networks, Integrated Veterans Care, Department of Veterans Affairs. The Claims Examiner reports to the Supervisor of the Beneficiary Claims Processing Unit. The primary function of the position is initial evaluation and processing of beneficiary submitted healthcare claims for payment.
Summary
This position is in the Beneficiary Claims Processing Unit, CHAMPVA program, 3.1 Network Development and Operations, Integrated External Networks, Integrated Veterans Care, Department of Veterans Affairs. The Claims Examiner reports to the Supervisor of the Beneficiary Claims Processing Unit. The primary function of the position is initial evaluation and processing of beneficiary submitted healthcare claims for payment.
Responsible for the review and processing of claims received under the CHAMPVA Program
Examine and evaluate relevant documentation related to the claims submitted for payment under the CHAMPVA Program. Prior to the processing of claims, the Claims examiner will review and research all submissions to determine all appropriate data is available to process the submission and to resolve other issues associated with the request for payment.
Review all claims for duplicate detection, all forms of missing or discrepant data, medical audits such as for ambulance, dental, travel and durable medical equipment as they pertain to the beneficiaries' claims.
Examines reimbursement of expenditures for accuracy, adequacy of documentation, or citations, compliance with regulations, and justification for CHAMPVA Family Member programs in a worldwide VA claims benefits program.
Research and processing of CRM tasks for both beneficiary and provider claims.
Analyze and resolve claims from appropriate suspense categories. Request to redevelop claims to issue proper payment after discrepant data has been identified and corrected.
Reviews the claims that fail critical system edits and medical utilization audits based on artificial intelligence (AI) scenarios. System edits include duplicate detection, all forms of missing or discrepant data, medical audits such as for ambulance, dental, mental health services, durable medical equipment (DME), and medical care cost recovery (MCCR) situations, Other Health Insurance (OHI) questionable cases, etc.
Identifies problems; determines accuracy and relevance of information; uses sound judgment to generate and evaluate alternatives, and to make recommendations.
Makes sound, well-informed, and objective decisions; perceives the impact and implications of decisions; commits to action, even in uncertain situations, to accomplish organizational goals; causes change.
Promotion Potential: The selectee may be promoted to the full performance level without further competition when all regulatory, qualification, and performance requirements are met. Selection at a lower grade level does not guarantee promotion to the full performance level.
Work Schedule: Monday - Friday 6:00a.m - 4:30p.m. 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. Position Description/PD#: Claims Examiner/PD66122A and PD66123A Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required
This position is in a bargaining unit
All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA.
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, 07/09/2024.
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-06 position you must have served 52 weeks at the GS-05.
For a GS-07 position you must have served 52 weeks at the GS-06.
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: GS-06 Specialized Experience: You must have one year of specialized experience equivalent to at least the next lower grade GS-05 in the normal line of progression for the occupation in the organization. Examples of specialized experience would typically include, but are not limited to:
Research to determine whether all required documentation is available, via a myriad of means to include, Paper submissions, DAPER, DATANET, Attachment Retrieval System (ARS) Datanet, ClamsXM, VistA query, and NPI (National Provider Identification)
Research to obtain information not directly addressed in the regulations and guidelines for routine and unusual situations.
Complete data entry transfer, calculations, and decision disposition utilizing working knowledge of complex types of claims regarding the processing of transactions based on statutes or policies.
Research a variety of complicated transactions to analyze and resolve issues involving claim submission utilizing automated healthcare claims processing systems, methods, procedures, and techniques.
GS-07 Specialized Experience: You must have one year of specialized experience equivalent to at least the next lower grade GS-06 in the normal line of progression for the occupation in the organization. Examples of specialized experience would typically include, but are not limited to:
Research claims for duplicate detection, all forms of missing or discrepant data, medical audits such as for ambulance, dental, travel and durable medical equipment as they pertain to beneficiaries claims..
Determine whether all required documentation is available, via a myriad of means to include, Paper submissions, DAPER, DATANET, Attachment Retrieval System (ARS) Datanet, ClamsXM, VistA query, and NPI (National Provider Identification)
Research a variety of complicated transactions to analyze and resolve issues involving payment and denials of claims utilizing automated healthcare claims processing systems, methods, procedures, and techniques.
Complete data entry transfer, calculations, and decision disposition utilizing working knowledge of complex types of claims regarding the processing of transactions based on statutes or policies
You will be rated on the following Competencies for this position:
Attention to Detail
Decision Making
Problem Solving
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: The work is primarily sedentary, with occasional requirements to walk around an office building to meet employees. Most work requirements involve using a computer and standard office automation equipment. The incumbent may need to stoop, bend, reach, or occasionally carry loads up to 20 pounds. Sitting in one location requires long periods in complete transactions, auditing, and research, using a computer with dual monitors and other standard office equipment
There is no educational substitution at this grade level.
Additional information
The Interagency Career Transition Assistance Plan (ICTAP) and Career Transition Assistance Plan (CTAP) provide eligible displaced Federal/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 ICTAP and 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.
Pursuant to VHA Directive 1193.01, VHA health care personnel (HCP) are required to be fully vaccinated against COVID-19 subject to such accommodations as required by law (i.e., medical, religious or pregnancy). VHA HCPs do not include remote workers who only infrequently enter VHA locations. If selected, you will be required to be fully vaccinated against COVID-19 and submit documentation of proof of vaccination before your start date. The agency will provide additional information regarding what information or documentation will be needed and how you can request a legally required accommodation from this requirement using the reasonable accommodation process.
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.
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 windowLearn more about federal 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.
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.
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 windowLearn more about federal 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.
To apply for this position, you must provide a complete Application Package which includes:
Resume
SF-50/ Notification of Personnel Action
The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to make sure you have included other documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), documentation to support Veterans Preference claims, or ICTAP/CTAP documentation (for displaced Federal employees). You will not be contacted for additional information.
Cover Letter
Performance Appraisal
Resume
Separation Notice (RIF)
SF-50/ Notification of Personnel Action
SF-50, Notification of Personnel Action (if applicable for Time in Grade and/or Eligibility):
Most recent SF-50 if you are a current or former Federal employee
An SF-50 showing 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
Award 50's do not provide sufficient information and will not be accepted for the purpose of verifying time-in-grade.
Examples of appropriate SF-50's include:
Within grade increases at the highest grade held; or
Promotions with an effective date more than one year old; or
SF-50's at the highest grade held with an effective date more than one year old.
Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit Feds Hire Vets - Veterans - Job Seekers - Veterans' Preference.
If you are relying on your education to meet qualification requirements:
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
All applicants are encouraged to apply online. To apply for this position, you must complete the questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 07/09/2024 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12457825.
To begin, click Apply Online to create a USA JOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire.
Click Submit My Answers to submit your application package.
NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.
To verify your application is complete, log into your USA JOBS account, https://my.usajobs.gov/Account/Login, select the Application Status link and then select the more information link for this position. The Application page will display the status of your application, the documentation received and processed, and any correspondence the agency has sent related to this application. Your uploaded documents may take several hours to clear the virus scan process. To return to an incomplete application, log into your USA JOBS account and click Update Application in the vacancy announcement. You must re-select your resume and/or other documents from your USA JOBS account or your application will be incomplete.
Workforce Management - Community Care
120 SE 6th Street Suite 102
Topeka, KS 66603
US
Next steps
Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.
You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center.
NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service. HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities. HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities. HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.
The Federal hiring process is set up to be fair and transparent. Please read the following guidance.
To apply for this position, you must provide a complete Application Package which includes:
Resume
SF-50/ Notification of Personnel Action
The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to make sure you have included other documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), documentation to support Veterans Preference claims, or ICTAP/CTAP documentation (for displaced Federal employees). You will not be contacted for additional information.
Cover Letter
Performance Appraisal
Resume
Separation Notice (RIF)
SF-50/ Notification of Personnel Action
SF-50, Notification of Personnel Action (if applicable for Time in Grade and/or Eligibility):
Most recent SF-50 if you are a current or former Federal employee
An SF-50 showing 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
Award 50's do not provide sufficient information and will not be accepted for the purpose of verifying time-in-grade.
Examples of appropriate SF-50's include:
Within grade increases at the highest grade held; or
Promotions with an effective date more than one year old; or
SF-50's at the highest grade held with an effective date more than one year old.
Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit Feds Hire Vets - Veterans - Job Seekers - Veterans' Preference.
If you are relying on your education to meet qualification requirements:
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
All applicants are encouraged to apply online. To apply for this position, you must complete the questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 07/09/2024 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12457825.
To begin, click Apply Online to create a USA JOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire.
Click Submit My Answers to submit your application package.
NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.
To verify your application is complete, log into your USA JOBS account, https://my.usajobs.gov/Account/Login, select the Application Status link and then select the more information link for this position. The Application page will display the status of your application, the documentation received and processed, and any correspondence the agency has sent related to this application. Your uploaded documents may take several hours to clear the virus scan process. To return to an incomplete application, log into your USA JOBS account and click Update Application in the vacancy announcement. You must re-select your resume and/or other documents from your USA JOBS account or your application will be incomplete.
Workforce Management - Community Care
120 SE 6th Street Suite 102
Topeka, KS 66603
US
Next steps
Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.
You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center.
NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service. HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities. HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities. HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.
Fair and transparent
The Federal hiring process is set up to be fair and transparent. Please read the following guidance.
