Apply on Employer Site

USAJOBS · 2 months ago

Claims Management and Customs and Border Protection Program Analyst (O-5 Billet) Non-Supervisory

Multiple Locations, USA

Full-time

Onsite

Mid Level

3+ years exp

USAJOBS is seeking a Claims Management and U.S. Customs and Border Protection Program Analyst to support the DHS ICE Health Service Corps' Health Plan Management Unit. The role involves claims adjudication, provider recruitment, training, fraud prevention, and acting as a liaison with CBP, HSI, and third-party administrators.

ConsultingGovernmentHuman ResourcesInformation TechnologyInternetStaffing Agency

No H1B

U.S. Citizen Only

Responsibilities

Serves as one of the primary points of contact and liaison to the third-party administrator on issues relating to medical claims processing and resolution and provider reimbursement

Serves as one of the primary points of contact and liaison to the U.S. Customs and Border Patrol, Office of Field Operations (OFO) and Homeland Security Investigations (HSI)

Provides oversight and consultation while reviewing, approving, denying, and adjudicating Medical Payment Authorization Requests for reimbursable healthcare services submitted by CBP, OFO, and HSI

Requests MedPARs for reimbursable health care services and medical claims review

Collaborates with the Claims Management Program to reconcile and resolve denied community provider claims and/or appeals

Provides oversight and consultation to CBP for recruitment and enrollment of providers into the IHSC provider network

Liaise regionally and, or, nationally with applicable internal and external stakeholders (CBP, and third-party administrator, off-site community providers) regarding medical claims processes, trainings, and principles

Provides orientation, training, and guidance to CBP and ICE custody staff responsible for overseeing individuals detained by CBP and ICE. This includes ensuring adherence to ICE policies, reporting requirements, and applicable ICE detention standards

Identifies potential areas for improvement in the managed care delivery system that warrants re-engineering to create efficiencies, marketing and increase cost containment controls, and ensure the provision of necessary and appropriate health care

Supports systems and mechanisms to identify potential fraud, waste and abuse

Evaluates, assesses, and recommends reimbursement methodologies and procedures

Assists third-party administrator when necessary in coordinating and obtaining information pertaining to Medical Provider Authorization Requests (MedPARs) or eligibility in the alien tracking system

Develops specific goals and plans to prioritize, organize, and accomplish positive outcomes

TDY as needed to provide clinical care support at IHSC-staffed detention facilities with critical staffing needs

Travel may be required- minimal (<15%)

Performs other duties as assigned

Qualification

Claims managementHealth care managementThird-party administrationContract managementICD-10 codingCPT codingDRG codingMS Office proficiencyAnalytical skillsCommunication skillsInterpersonal skillsFlexibility

Required

Bachelor's degree in business administration, Finance, Health Care Management or related field preferred; or a graduate degree with extensive experience in claims management, benefit, third-party administration, or contract management preferred

Minimum 3 years of experience working with health care organizations, third-party administrators, or health care providers

Performs tasks requiring the highest level of independence; exhibits preparation and flexibility to adapt to unusual circumstances requiring variations in approach, and in the presence of incomplete or conflicting data related to MedPARs and claims adjudication

Ability to navigate in an electronic work environment including electronic health records, web-based training and communications

Ability to establish and maintain positive working relationships in a multidisciplinary environment. Establish contact with people in other federal departments or outside the federal government

Requires virtual face to face contact and telephone dialogue on a routine basis

Should possess some knowledge of International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10), current procedural terminology (CPT), diagnosis-related group (DRG), and other Centers for Medicare and Medicaid Services (CMS) coding/billing requirements

Ability to provide technical advisory services to customers on matters related to medical claims processing, provision of special medical care, and the purchase or rental of durable medical goods

Demonstrated ability to maintain patient confidentiality and the confidentiality of all records in compliance with the Privacy Act and HIPAA regulations, exercising sound judgment and discretion in all work activities

Skill in applying analytical and evaluative methods and techniques to issues concerning the efficiency and effectiveness of providing health care, and ensuring on-time and accurate billing and payment

Ability to manage multiple tasks and prioritize based on mission needs and urgencies

Skills in applying analytical and evaluative methods and techniques to issues concerning the efficiency and effectiveness of providing health care, and ensuring on-time and accurate billing and payment

Flexibility and ability to adapt to sudden changes in schedules and work-related requirements

Knowledge and proficiency in MS Office Applications, Excel, Outlook, MS Teams and SharePoint

Completes all initial, annual and ad hoc training as required/assigned

Maintains patient confidentiality, and confidentiality of all records, in compliance with the Privacy Act and HIPAA regulations in all work activities