Legal Administrative Specialist (Insurance Benefits Claims Examiner)

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.

Salary

• $68,405 - $88,926/year

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
• 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.

Merit promotion applicants must meet the time-in-grade requirement as defined in 5 CFR 300, Subpart F. One year at the GS-7 level is required to meet the time-in-grade requirements for the GS9 level.

You must meet all qualification and eligibility requirements within 30 days of 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. Other Information

Relocation expenses will not be paid.Current OPM employees may qualify as an exception.

Incentive payments may be considered.

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.

This job opportunity announcement may be used to fill additional similar vacancies across OPM.
During the application process you will 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.

Veterans Employment Opportunity Act (VEOA): To be eligible for a VEOA appointment under Merit Promotion procedures, the veteran must be a preference eligible or a veteran separated after 3 years or more of continuous active service performed under honorable conditions.

Noncompetitive Appointment Authorities: For more information on noncompetitive appointment authority eligibility
requirements visit the following websites:

• Persons with Disabilities-Schedule A
• Special Hiring Authorities for Veterans
• Special Hiring Authority for Certain Military Spouses
• Other Special Appointment Authorities

Males born after 12-31-59 must be registered or exempt from Selective Service (see https://www.sss.gov/Home/Registration)

Reasonable Accommodation Requests: If you believe you have a disability (i.e., physical or mental), covered by the Rehabilitation Act of 1973 as amended that would interfere with completing the USA Hire Competency Based Assessments, you will be granted the opportunity to request an RA in your online application. Requests for RA for the USA Hire Competency-Based Assessments and appropriate supporting documentation for RA must be received prior to starting the USA Hire Competency-Based Assessments. Decisions on requests for RA 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 an RA, 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

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
   • Most recent Performance Appraisal, optional
   • Your most recent Promotion, Within Rate Increase (WRI/WGI), or Appointment/Conversion SF-50 or Notification of Personnel Action if applying as a current or former Federal / OPM Employee showing you are/were in the competitive service and the highest grade or promotion potential held, required if applying as a current or former Federal / OPM employee.
   • 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.
   • Veterans Employment Opportunity Act Eligible: DD-214, SF-15 Form and VA letter, or certification of expected discharge or release from active duty under honorable conditions within 120 days.
   • Schedule A, Persons with Disabilities Appointment Eligibles: Schedule A letter from a physician, local, state, or federal rehabilitation office citing your eligibility under 5 CFR 213.3102 (u).
   • Certain Family Members Eligible under E.O. 12721: Your most recent non-award SF-50 and performance appraisal.
   • Certain Military Spouses Eligible under E.O. 13832: Permanent Change of Station (PCS) orders; OR verification of the member's 100% disability (VA Letter); and/or verification of the member's death while on active duty (DD-1300 and Death Certificate) AND verification of the marriage to the service member (i.e., a marriage license or other legal documentation verifying marriage).

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.

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 submit all required documentation as specified in the How to Apply and Required Documents section. The complete application package must be submitted by 11:59 PM (ET) on the closing date of the announcement 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 11:59 PM (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 assessments 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 reused.

For more general information, system requirements, reasonable accommodation information, and to request assistance regarding the 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 record, and click Edit my application. This option will no longer be available once the announcement has closed.

To view the announcement status or your 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/12596206

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. Learn more about federal benefits.

Review our benefits