USAJOBS · 1 day ago
Claims Management Program Administrator (O-6 Billet) Supervisory
Anywhere in the U.S. (remote job), USA
Full-time
Remote
Mid, Senior Level
5+ years exp
Maximize your interview chancesConsultingGovernment
No H1B
U.S. Citizen OnlySecurity Clearance Required
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Responsibilities
Assists HPMU senior leadership in overall responsibility for the successful planning, design, execution, monitoring, and management of Health Plan Management Unit activities.
Assumes leadership role as Acting HPMU Chief or Deputy when necessary.
The Claims Management Program Administrator (CMPA) has direct oversight of personnel, program activities and policies related to medical claims and provider recruitment.
Responsible for providing first-line supervision and administrative oversight of the Supervisory Claims Management Program Analyst (CM RPAs), Supervisory IHSC CBP Program Analyst, IHSC CBP Program Analyst, CMP Analysts (CM PA), Provider Relations Liaisons (PRL) and a CMP Referral Coordinator (RC) that supports the CMP.
Plans, schedules, and assigns work to be accomplished by subordinate claims management staff; determines and sets program policies and goals, initiates organizational changes, delegates authority to subordinate supervisors, and holds program supervisors responsible for the performance of their organizational components.
Directs CMP of nationwide scope and importance. The CMP is essential to the mission of the ICE/ERO/IHSC and affects large numbers of people on a long-term or continuing basis.
Directs, implements, creates, and manages preparation of program planning, design, execution, monitoring, and management of Claims Management (CM) initiatives and projects.
Serves as Subject Matter Expert and representative for Claims Management Program with Data Analysis Office (DAO), Utilization Management Program, third party claims vendor, Field Medical Coordination Unit (FMCU), Health Information & Technology Unit (HITU) and IHSC's Executive Governing Board (EGB).
As operational liaison, produces Claims Management data analysis reports for taskings related to data and legal cases against ICE (Immigration, Customs & Enforcement), U.S. Customs and Border Protection (CBP), Homeland Security Investigations (HSI), and CBP's Office of Field Operations (OFO) requested by OIG (Office of Inspector General), OPLA (Office of Policy Legal Advisors), CRCL (Civil Right & Civil Liberties), OSEC (Office of the Secretary), congressional & media inquiries related to CM.
Serves as CM representative between IHSC, third party claims vendor, CBP components, and ICE ERO components in coordinating care and recruitment of community-based specialty care for noncitizens.
Develops, reviews, and revises national level directives, standard operating procedures, and guides for CMP Analyst, CBP CMP Analyst and Provider Network Programs.
Provides oversight and consultation regarding Medical Payment Authorization Requests (MedPARs) for reimbursable health care services, medical claims review and systems.
Liaise regionally and nationally with applicable internal and external stakeholders, including in other federal departments or outside the federal government, (e.g., Customs and Border Patrol, Office of Field Operations, Homeland Security Investigations and third-party claims vendor) regarding medical claims processes, trainings, and principles. This requires contact via teleconferences and/or telephone dialogue on a routine basis.
Provides orientation and guidance to the respective ICE, custody, and medical staff members of facilities in which ICE noncitizens are held regarding ICE policies, reporting requirements, and applicable ICE detention standards.
Serves as Claims Management Program lead for IHSC's third party claims vendor $100M+ Service Level Agreement (SLA) to include: certification of invoices, certification of funds availability, and approval of miscellaneous expenses.
Liaises with IHSC staff, as one of the primary points of contact for the third-party claims vendor on issues relating to pharmacy benefits and claims, medical claims processing and resolution, and provider reimbursement. Coordinates and collaborates with internal and external stakeholders, including 5,000+ community providers, CBP stations/sectors, nonIHSC facilities and IHSC facilities to manage and adjudicate medical claims to meet the ICE/IHSC mission.
Develops, evaluates, and coordinates a national level CMP and related functions to ensure adherence to industry practices in eligibility verification, authorization of care, claims management denials and appeals to minimize adverse outcomes related to timely filing and maintaining a Provider Network to provide quality specialty care to ICE noncitizens.
Develop and submit quarterly and annual reports, i.e., Strategic Plan MAP/KPIs, training, Business Plan Updates, etc. to the HMP Unit Chief and Deputy Unit Chief.
As a Government Technical Monitor (GTM), the incumbent works directly with the Contracting Officer Representatives (COR) with respect to contract staff performance, time, and compliance as needed.
Performs other duties and responsibilities as assigned.
Qualification
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Required
You must be a U.S. citizen to apply for this position.
You must successfully pass a background investigation.
You must successfully pass a drug screen.
Males born after 12/31/59 must certify registration with Selective Service.
Unless otherwise noted, you must meet all requirements by the closing date of the announcement.
Upon appointment to this position, officers will be required to serve a new 18-month commitment to IHSC.
Applicants must be a current USPHS Commissioned Corps Officer who works at IHSC.
Incumbent must possess a minimum of a bachelor's degree but graduate degree in Business Administration, Finance or Health Care Management or related field preferred; or a graduate degree with extensive experience in claims management, benefit, third-party administration, or contract management with a minimum 5 years of professional experience relevant to the officer's category.
Of the total professional experience, officer must possess at least 4 years of experience related to management, administration, or evaluation of public health programs.
Three years of supervisory experience.
Incumbent must possess at minimum, a Level II COR 40-hour course certificate or must obtain after one year of hire through the Defense Acquisition University (DAU) and Federal Acquisition (FAI) Cornerstone OnDemand (CSOD) online comprehensive learning platform.
Able to obtain knowledge and maintain proficiency in, applicable IHSC policies and detention health care standards [i.e., ICE National Detention Standards and Performance Based National Detention Standards (PBNDS), National Commission on Correctional Healthcare (NCCHC), American Correctional Association (ACA) and Family Residential Standards (FRS)]
Knowledge of medical, administrative, ethical, and legal requirements and standards related to healthcare delivery, claims management and medical necessity.
Possess basic 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.
Experience utilizing and navigating electronic health records and other web-based application programs.
Ability to critically analyze situations, data, and information, and be able to develop and pose probing questions, identify problems, and make recommendations towards their resolution.
Maintains clinical professional skills via continuing education opportunities.
Computer literate on MS Office applications and Sharepoint.
Preferred
Graduate degree in Business Administration, Finance or Health Care Management or related field.
Minimum of three-years' experience in correctional/detention health programs preferred.
Preferably a minimum of three years in an office now part of IHSC.
Project Management and/or Program Management experience preferred.
Benefits
Relocation expenses reimbursed: Yes—You may qualify for reimbursement of relocation expenses in accordance with agency policy.
Company
USAJOBS
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Funding
Current Stage
Late StageCompany data provided by crunchbase
