Legal Administrative Specialist (Insurance Benefits Claims Examiner) Job in Washington, DC

Vacancy No. 25-DMM-12596208-DE Department Office of Personnel Management
Salary $68,405.00 to $88,926.00 Grade 9 to 9
Perm/Temp Permanent FT/PT Full-time
Open Date 11/26/2024 Close Date 12/2/2024
Job Link Apply Online Who may apply Public
Locations:
Washington, DC


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 FEHB carriers to ensure Federal enrollees receive the benefits that OPM negotiated with carriers and respond to general inquiries concerning FEHB Program disputed claim regulations, health insurance coverage, and Federal enrollment eligibility.

Duties

  • Respond to Federal Employees Health Benefits (FEHB) inquiries from Federal 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 FEHB 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.

Requirements

Conditions of Employment

  • Must be a U.S. Citizen or National
  • Males born after 12-31-59 must be registered or exempt from Selective Service (see https://www.sss.gov/Home/Registration)
  • Suitable for Federal employment, determined by a background investigation
  • May be required to successfully complete a probationary period
  • Complete the initial online assessment and USAHire Assessment, if required
  • 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

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.

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

There are no educational requirements for this position.

Additional information

Incentive payments may be considered.

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

If you are unable to apply online and would like to request information about the Alternate Application process, please use the contact information at the bottom of this announcement.

Career Transition Assistance Programs: These programs apply to employees who have been involuntarily separated from a Federal service position within the competitive service or Federal service employees whose positions have been deemed surplus or no longer needed. To receive selection priority for this position, you must: 1) meet CTAP or ICTAP eligibility criteria; 2) be rated well-qualified for the position and 3) submit the appropriate documentation to support your CTAP or ICTAP eligibility. For more information visit: http://www.opm.gov/rif/employee_guides/career_transition.asp.

Reasonable Accommodation Requests: If you believe you have a disability (i.e., physical or mental), covered by the Rehabilitation Act of 1973 as amended and Americans with Disabilities Act 1990 as amended, that would interfere with completing the USA Hire Competency Based Assessments, you will be granted the opportunity to request a reasonable accommodation in your online application. Requests for Reasonable Accommodations for the USA Hire Competency Based Assessments and appropriate supporting documentation for Reasonable Accommodation must be received prior to starting the USA Hire Competency Based Assessments. Decisions on requests for Reasonable Accommodations are made on a case-by-case basis. If you meet the minimum qualifications of the position, after notification of the adjudication of your request, you will receive an email invitation to complete the USA Hire Competency Based Assessments, based on your adjudication decision. You must complete all assessments within 48 hours of receiving the URL to access the USA Hire Competency Based Assessments, if you received the link after the close of the announcement. To determine if you need a Reasonable Accommodation, please review the Procedures for Requesting a Reasonable Accommodation for Online Assessments here: https://help.usastaffing.gov/Apply/index.php?title=Reasonable_Accommodations_for_USA_Hire

Benefits

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.

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.

For Category Rating: Once the application process is complete, a review of your resume will be made and compared against your responses to the assessment questionnaire to determine if you are qualified for this job. If, after reviewing your resume, a determination is made that you have inflated your qualifications and/or experience, you may lose consideration for this position. Please follow all instructions carefully. Errors or omissions may affect your eligibility. Qualified candidates will be assigned to one of the three quality categories: Qualified, Well Qualified, or Best Qualified. Qualified Category = Does not exceed the basic qualifications requirements described in the "Qualifications" section of this announcement. Well Qualified Category = Meets the basic qualifications requirements described in the "Qualifications" section of this announcement and demonstrates proficiency in the Critical Competencies defined below. (This category must be met to be considered under ICTAP procedures) Best Qualified Category = Meets the basic qualifications requirements described in the "Qualifications" section of this announcement and excels in the Critical Competencies defined below. The category assignment is a measure of the degree in which your background matches the competencies required for this position.

Your qualifications will be evaluated on the following competencies (knowledge, skills, abilities and other characteristics):

  • Attention to Detail
  • Customer Service
  • Decision Making
  • Flexibility
  • Insurance
  • Integrity/Honesty
  • Interpersonal Skills
  • Knowledge of insurance industry practices
  • Learning
  • Oral Communication
  • Problem Solving
  • Reading Comprehension
  • Reasoning
  • Research
  • Self-Management
  • Stress Tolerance
  • Teamwork
  • Writing


Overstating your qualifications and/or experience in your application materials or application questionnaire may result in your removal from consideration. Cheating on an assessment may also result in your removal from consideration.

The Category Rating Process does not add veterans' preference points or apply the "rule of three," but protects the rights of veterans by placing them ahead of non-preference eligibles within each category. Preference eligibles who meet the minimum qualification requirements and have a compensable service-connected disability of at least 10 percent or higher will be listed in the highest quality category (except in the case of scientific or professional positions at the GS-09 level or higher).

Required Documents

? ?To apply for this position, you must provide a complete Application Package which includes:

  1. Your Resume showing the applicant's name, email address, work schedule, hours worked per week, dates of employment, and duties performed to include pay plan, series, and grade level for relevant federal experience. Your resume must show complete information for each job entry to support minimum qualifications.
  • Do not include the following types of information in your resume:
    • Classified or government sensitive information
    • Social Security Number (SSN)
    • Photos of yourself
    • Personal information, such as age, gender, religious affiliation, etc.
    • Encrypted and digitally signed documents
  1. Other supporting documents:
    • Cover Letter, optional
    • College Transcript(s), if qualifying based on education
    • If you are requesting a reasonable accommodation to the USA Hire Competency Based Assessments, submit documentation to support your request including the Reasonable Accommodation Request Form found here.
    • Veterans' Preference documentation, if applicable (e.g. DD-214 Member Copy 4 showing type of discharge/character of service; Current Active Duty members must submit a certification of expected discharge or release from active duty under honorable conditions dated within 120 days; SF-15 Form and related documentation; VA letter.) If you are a veteran and you are claiming 5-point veterans' preference, you must submit a copy of your DD-214 or other proof of eligibility.
      If you are a veteran and you are claiming 10-point veterans' preference, you must also submit an SF-15, "Application for 10-Point Veterans' Preference" plus the proof required by that form. For more information on veterans' preference click here.
    • Career Transition Assistance Program/Interagency Career Transition Assistance Program documentation, if applicable (e.g. Certification of Expected Separation, Reduction-In-Force Separation Notice, or Notice of Proposed Removal; SF-50 that documents the RIF separation action; and most recent performance appraisal.)
    • Worker's Compensation Separation: Agency certification of inability to place employee AND Notification of Separation OR Separation SF-50.
    • Disability Annuity Termination: Notification from OPM of disability annuity termination AND Separation SF-50 of the last position held.
    • Military Reserve or National Guard Technician Special Disability Retirement Annuity under 5 U.S.C. 8337(h) or 8456: Certification of special disability retirement annuity from a military department or National Guard Bureau AND Separation SF-50 of the last position held.
Failure to submit any of the above mentioned required documents may result in loss of consideration due to an incomplete application package. It is your responsibility to ensure all required documents have been submitted.

If you are relying on your education to meet qualification requirements:

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. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education.

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.

How to Apply

Please read the entire announcement and all the instructions before you begin an application. To apply and be considered for this position, you must complete all required questionnaires, assessments, and the required documentation as specified in the How to Apply and Required Documents section. The complete application package must be submitted by 11:59 PM (EST)on 12/02/2024 to receive consideration.

The application process is as follows:

  1. Click the Apply Online button.
  2. Answer the questions presented in the application and attach all necessary supporting documentation.
  3. Click the "Submit Application" button prior to 11:59pm (ET) on the announcement closing date.
  4. If you are required to complete any USA Hire Assessments, you will be notified after submitting your application. The notification will be provided in your application submission screen and via email. The notification will include your unique assessment access link to the USA Hire system and the completion deadline. Additionally, in USAJOBS you can click "Track this application" to return to your assessment completion notice.
  5. Access USA Hire using your unique assessment link. Access is granted through your USAJOBS login credentials.
  6. Review all instructions prior to beginning your assessments. You will have the opportunity to request a testing accommodation before beginning the assessments should you have a disability covered under the Rehabilitation Act of 1973 as amended.
  7. Set aside at least 3 hours to take the USA Hire assessments; however most applicants complete the assessment in less time. If you need to stop the assessments and continue later, you can re-use your unique assessment link.
  8. Your responses to the USA Hire assessments will be reused for one year (in most cases) from the date you complete an assessment. If future applications you submit require completion of the same assessments, your responses will be automatically used.
For more general information, system requirements, reasonable accommodation information, and to request assistance regarding the use of USA Hire assessments, review the following resources:

https://help.usastaffing.gov/Apply/index.php?title=USA_Hire_Assessments

To update your application, including supporting documentation: During the announcement open period, return to your USAJOBS account, find your application and click Edit My Application. This option will no longer be available once the announcement has closed.

To view the announcement status or application status: Click on this: https://www.usajobs.gov/Help/how-to/application/status/ . Your application status page is where you can view your application status, USA Hire assessment completion status, and review your notifications sent by the hiring agency regarding your application.

You may preview the assessment questionnaire by clicking here: https://apply.usastaffing.gov/ViewQuestionnaire/12596208

Agency contact information

OPM Human Resources
Address
OPM Human Resources
1900 E St., NW
Washington, DC 20415
US
Learn more about this agency

Next steps

Once referred, you may be asked to complete a structured interview, written demonstration, and/or fit interview. Deliberate attempts to falsify information may be grounds for not selecting you or for dismissing you from the position/agency during the probationary period.

Once your online application is submitted you will receive a confirmation notification by email. Your application will be evaluated. You will receive another notification about the status of your application.

We expect to make a job offer within 40 days after the closing date of the announcement. After making a tentative job offer, we will conduct a suitability/security background investigation.

An agency may not request, orally, in writing, or electronically through the USA Jobs website or other electronic means, that an applicant for appointment for a position in the civil service disclose criminal history record information before the appointing agency extends a conditional offer of employment. If you believe you were asked about your criminal history improperly, contact the agency or visit https://www.opm.gov/about-us/careers-at-opm/opportunities/


Note: We cannot accept applications on behalf of Federal Agencies. Application instructions are listed within the Job Description.


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