Claims Examiner

Summary

This position is in the Specialty Programs Department, Veteran and Family Member Programs (VFMP), within the Veterans Health Administration (VHA). The position is in Lakewood, Colorado.

Duties

***THIS IS NOT A VIRTUAL POSITION, YOU MUST LIVE WITHIN OR BE WILLING TO RELOCATE WITHIN A COMMUTABLE DISTANCE OF THE DUTY LOCATION*** Major duties and responsibilities include: Processing foreign medical claims on a complex manual system, without automation or artificial intelligence assistance Utilizing an extensive knowledge of diagnostics and medical services Performing complex diagnostic and procedure coding Independently applying and interpreting laws and regulations set forth in the program policy to adjudicate medical claims Examining, developing, and evaluating relevant documentation related to claims submitted for payment Independently performing research to determine whether conditions treated on medical claims are service-connected or associated with or aggravated by the Veteran's listed service-connected condition(s) Utilizing medical reference books, medical dictionaries, online medical websites, coding software, etc. in performing research related to complex medical claims Converting foreign currency to the equivalent amount in United States dollars Applying expert understanding of the laws and regulations governing the FMP and all technical aspects of processing FMP claims to perform research and responds to Congressional and White House inquiries. Performing other duties as assigned Work Schedule: To be discussed during interview Recruitment & Relocation Incentives: Not authorized Critical Skills Incentive (CSI): Not approved Telework: This position may be authorized for ad hoc telework. Telework eligibility will be discussed during the interview process. Ad hoc is defined as occasional, non-recurring telework.

Qualifications

To qualify for this position at the GS-8 level, you must have: At least one (1) full year of specialized experience that equipped you with the knowledge, skills, and abilities to successfully perform the duties of this position (Claims Examiner). To be creditable, specialized experience must have been equivalent to at least the next lower grade level (GS-7) in the Federal service. Specialized experience is defined as experience processing medical claims and applying comprehensive knowledge of provider relations, reimbursement methods, coordination of benefits, and medical cost-recovery practices. Note: Experience must be fully documented on your resume and must include job title, duties, month and year start/end dates AND hour worked per week. For more information on these qualification standards, please visit the United States Office of Personnel Management's website at https://www.opm.gov/policy-data-oversight/classification-qualifications/general-schedule-qualification-standards/.

Education

There is no educational substitution at this grade level.