• Administers the medical disputed claims review process and provides medical guidance on disputed claims, policies, procedures, and documentation.
• Serves as a medical subject matter expert for claims examiners, specialists, leadership, and internal and external stakeholders.
• Coordinates independent medical consultant reviews and ensures medical decisions align with contract provisions, limitations, and exclusions.
• Reviews medical aspects of carrier benefit proposals and supports benefit negotiations with medical analysis and recommendations.
• Develops project plans and recommends process improvements to improve the quality and efficiency of disputed claims reviews.
• Trains Legal Administrative Specialists on appeal documentation, case review, medical issues, coding systems, and legal sufficiency considerations.
• Researches medical techniques, services, trends, and industry developments to support defensible medical-review analyses and benefit decisions.

Conditions of employment

• Must be a U.S. Citizen or National
• Males born after 12-31-59 must be registered for Selective Service
• Suitable for Federal employment, determined by a background investigation
• May be required to successfully complete a probationary period
• Candidates will not be hired based on their race, sex, color, religion, or national origin
• Complete the initial online assessment and USAHire Assessment, if required
• You will be required to report to an OPM assigned office.
• 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

Basic Education Requirement: All applicants must have a graduate or higher level degree, bachelors degree, associate degree, or diploma from an accredited professional nursing educational program. This education must have been accredited by the Commission on Collegiate Nursing Education,Council on Accreditation of Nurse Anesthesia Educational Programs, Accreditation Commission for Midwifery Education, or an accrediting body recognized by the U.S. Department of Education at the time the degree was obtained.

Licensure Requirement: Applicants must have passed the National Council Licensure Examination. In addition, they must possess a current, active, full, and unrestricted license or registration as a professional nurse from a State, the District of Columbia, the Commonwealth of Puerto Rico, or a territory of the United States.

Experience Requirements:

For the GS-13 Grade Level: Applicants must have one year of specialized experience equivalent to at least the GS-12 level in the Federal service, or equivalent, performing nursing, health insurance, medical claims, or health benefits review work that includes:

• Reviewing medical records, claims information, benefit provisions, or appeal materials to support decisions on health care services, coverage, or medical necessity;
• Applying medical terminology, coding information, health care procedures, or clinical standards to evaluate health benefit claims, appeals, or disputed coverage issues;
• Preparing written analyses, recommendations, correspondence, or case documentation involving medical claims, health benefits, or insurance coverage issues; and
• Providing technical guidance, training, or consultation to staff or stakeholders on medical claims review, health benefit interpretation, or appeal documentation requirements.

For the GS-14 Grade Level:

Applicants must have one year of specialized experience equivalent to at least the GS-13 level in the Federal service, or equivalent, performing nursing, health insurance, medical claims, or health benefits review work that includes:

• Independently evaluating medical records, claims information, benefit provisions, or appeal materials to develop recommendations on health care services, coverage, or medical necessity;
• Applying medical terminology, coding information, health care procedures, clinical standards, and insurance benefit provisions to resolve disputed claims or coverage issues;
• Preparing written medical analyses, recommendations, determinations, correspondence, or case documentation used to support benefit decisions or appeal responses;
• Providing technical guidance, training, or consultation to staff, managers, contractors, or stakeholders on medical claims review, health benefit interpretation, or appeal documentation requirements; and
• Identifying trends, issues, or process concerns in medical claims or disputed claims review and recommending changes to improve consistency, timeliness, or decision support.

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.

How you will be evaluated

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

You will be evaluated based on how well you meet the qualifications listed in this vacancy announcement. Your qualifications will be evaluated based on your application materials (e.g., resume, supporting documents), your responses on the application questionnaire, and your responses to all assessments required for this position. You will be assessed on the following competencies (knowledge, skills, abilities, and other characteristics):

• Attention to Detail
• Customer Service
• Decision Making
• Flexibility
• Influencing/Negotiating
• Integrity/Honesty
• Interpersonal Skills
• Learning
• Reasoning
• Self-Management
• Stress Tolerance
• Teamwork

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.


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 (obtain a score of 85 or higher on the assessments); 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.

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. Only the first 2 pages of the resume/application will be used to verify minimum qualifications. Please be sure to include specific dates of employment and work schedule(s).

• 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, sex, religious affiliation, etc.
    • Encrypted and digitally signed documents

2. This position has a basic education requirement; you MUST submit a copy of your transcripts for further consideration.
3. Proof of Licensure
4. Other supporting documents:
   • Cover Letter, optional
   • Career Transition Assistance Program (CTAP)/Interagency Career Transition Assistance Program (ICTAP)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.)
   • 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.

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.?

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