Summary
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.
This job is open to
- Career transition (CTAP, ICTAP, RPL)
Federal employees who meet the definition of a “surplus” or “displaced” employee.
- Federal employees – Competitive service
Current or former competitive service federal employees.
- Individuals with disabilities
- Land & base management
Certain current or former term or temporary federal employees of a land or base management agency.
- Military spouses
- Veterans
This job is also open in another announcement to:
- Career transition (CTAP, ICTAP, RPL)
- The public
This job is also open in another announcement to:
- Career transition (CTAP, ICTAP, RPL)
- The public
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.
Requirements
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 USA Hire 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-07 Grade Level: Applicants must meet at least ONE of the qualification requirements described under A, B, or C below:
[A] EDUCATION (Undergraduate and/or Graduate):
SUPERIOR ACADEMIC ACHIEVEMENT PROVISIONS:
A bachelor’s degree in Healthcare Administration, Health Policy, Business Administration, Management or other related degree, plus at least one of the following superior academic achievement provisions:
1. A grade-point average (GPA) or B (3.0 or higher on a 4.0 scale) for all completed undergraduate courses, or courses completed in the last two years of undergraduate curriculum; -Or-
2. A grade-point average (GPA) of B+ (3.5 or higher on a 4.0 scale) for the required courses in your major field of study, or required courses in your major completed in the last two years of undergraduate study; -Or-
3. Rank in the upper one-third of your class in the college, university, or major subdivision at the time of application; -Or-
4. Elections to membership in a national scholastic honor society, other than freshman honor societies. Honor societies that have been approved are listed in the Association of College Honor Societies.
GRADUATE EDUCATION: One full year of graduate level study in Healthcare Administration, Health Policy, Business Administration, Management or other related degree. (An academic year of graduate education is considered to be the number of credit hours that the school attended has determined to represent one academic year of full-time study).
[B] EXPERIENCE: You must have one year of specialized experience (equivalent in difficulty and complexity to the GS-05 grade level or comparable pay band in the Federal service) which demonstrates ALL of the following:
- reviewing disputed health benefits claims and appeals;
- reviewing basic information on claims requests to ensure all relevant information is listed; and
- searching records or material to develop, examine, adjust, or reconsider a claim settlement.
[C] COMBINATION OF EDUCATION AND EXPERIENCE TO QUALIFY AT THIS LEVEL: You must have a combination of specialized experience and education beyond a bachelor’s degree. The education and experience must be directly related to the work of the position to be filled. To calculate your percentage of graduate education, divide the number of graduate semester hours by 18. If your education is in quarter hours, convert to semester hours by multiplying the number of quarter hours earned by 2/3rds. To determine your percentage of qualifying experience, you must divide your total number of months of qualifying experience by the required number of months of experience. Add your percentages of education and experience. The two percentages must total at least 100%.
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 time-in-grade requirement as defined in 5 CFR 300, Subpart F.
- One year at the GS-05 level is required to meet the time-in-grade requirements for the GS-07 level.
- One year at the GS-07 level is required to meet the time-in-grade requirements for the GS-09 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.
Education
IF YOU ARE USING YOUR EDUCATION TO QUALIFY: You MUST provide transcripts, official or unofficial transcripts are acceptable. All materials must be submitted by the closing date of the announcement.
PASS/FAIL COURSES: If more than 10 percent of your undergraduate course work (credit hours) was taken on a pass/fail basis, your claim of superior academic achievement must be based upon class standing or membership in an honor society.
GRADUATE EDUCATION: One academic year of graduate education is considered to be the number of credits hours that your graduate school has determined to represent one academic year of full-time study. Such study may have been performed on a full-time or part-time basis. If you cannot obtain your graduate school’s definition of one year of graduate study, 18 semester hours (or 27 quarter hours) should be considered as satisfying the requirement for one year of full-time graduate study.
FOREIGN EDUCATION: If you are using education completed in foreign colleges or universities to meet the qualification requirements, you must show that the education credentials have been evaluated by a private organization that specializes in interpretation of foreign education programs and such education has been deemed equivalent to that gained in an accredited U.S. education program; or full credit has been given for the courses at a U.S. accredited college or university. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html
Additional information
Relocation expenses will not be paid.Current OPM employees may qualify as an exception.
Incentive payments may be considered.
This job opportunity announcement may be used to fill additional similar vacancies across OPM.
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 and Americans with Disabilities Act 1990 as amended, that would interfere with completing the USA Hire Competency Based Assessments, you will be granted the opportunity to request a reasonable accommodation in your online application. Requests for Reasonable Accommodations for the USA Hire Competency Based Assessments and appropriate supporting documentation for Reasonable Accommodation must be received prior to starting the USA Hire Competency Based Assessments. Decisions on requests for Reasonable Accommodations 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. 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 a Reasonable Accommodation, 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
- 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. Opens in a new windowLearn more about federal benefits.
Review our benefits
Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.
How You Will Be Evaluated
You will be evaluated for this job based on how well you meet the qualifications above.
Once the application process is complete, your resume will be used to determine whether you meet the job qualifications listed on this announcement. If you are minimally qualified for this job, your resume will be compared to your responses on the Occupational Questionnaire. If you rate yourself higher than is supported by your application materials, your responses may be adjusted and/or you may be excluded from consideration for this job. Your qualifications will be evaluated on the following competencies(knowledge, skills, abilities and other characteristics):
- Attention to Detail
- Customer Service
- Decision Making
- Flexibility
- Insurance
- Integrity/Honesty
- Interpersonal Skills
- Knowledge of insurance industry practices
- Learning
- Oral Communication
- Reading Comprehension
- Reasoning
- Research
- Self-Management
- Stress Tolerance
- Teamwork
- Writing
In order to be considered for this position, you must complete all required steps in the process. In addition to the application and application questionnaire, this position requires an online assessment. The online assessment measures critical general competencies required to perform the job.
All qualified Non Competitive applicants and the best qualified Merit Promotion applicants will be referred to the hiring manager for 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; 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.
- 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. Opens in a new windowLearn more about federal benefits.
Review our benefits
Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.
- Required Documents
As a new or existing federal employee, you and your family may have access to a range of benefits. Your benefits depend on the type of position you have – whether you’re a permanent, part-time, temporary or an intermittent employee. You may be eligible for the following benefits, however, check with your agency to make sure you’re eligible under their policies.
To apply for this position, you must provide a complete Application Package which includes:
- Your Resume showing applicant’s name, email address, work schedule, hours worked per week, dates of employment and duties performed.
- Transcripts/Registration/License: If qualifying on education/position requires education, you must submit copies of your transcripts and if required for the position, submit an active, current registration/license
- Other supporting documents:
- Cover Letter, optional
- 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, Veterans Recruitment Appointment, and 30% Disabled Veteran 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, that lists you as authorized to accompany the Military member to the new duty permanent station; 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).
- Interchange Agreement with Other Merit Systems Eligible: Documentation of eligibility as listed in each individual interchange agreement.
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.
If you are relying on your education to meet qualification requirements:
Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education.
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
- How to Apply
Please read the entire announcement and all the instructions before you begin an application. To apply for this position, you must complete the initial online application, to include submission of the required documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (EST) on 04/19/2023 to receive consideration. The application process is as follows:
- To begin the application process, click the Apply Online button.
- Answer the questions presented in the application and attach all necessary supporting documentation.
- Click the “Submit Application” button prior to 11:59pm (ET) on the announcement closing date.
- After submitting an online application, you will be notified whether or not you are required to take additional online assessments through the USA Hire Competency Based Assessment system. This message will be delivered to you both on screen and via email notification.
- If you are asked to take the USA Hire Competency Based Assessments, you will be presented with a unique URL to access the USA Hire system. Access to USA Hire is granted through your USAJOBS login credentials. Be sure to review all instructions prior to beginning your USA Hire Assessments. Note, set aside at least 3 hours to take these assessments; however, most applicants complete the assessments in less time. If you need to stop the assessments and continue at a later time, you can re-use the URL sent to you via email and also found on the “Additional Application Information” page that can be located in the application record in your USAJOBS account.
To update your application, including supporting documentation, at any time during the announcement open period by return to your USAJOBS account. There you will find a record of your application, the application status, and an option to “Update Application.” This option will no longer be available once the announcement has closed.
To verify the status of your application both during and after the announcement open period, log into your USAJOBS account, all of your applications will appear on the Welcome screen. The application record in your USAJOBS account provides an “Additional Application Information” page that provides information regarding the documentation you submitted and any correspondence we have sent related to this application. The Application Status will appear along with the date your application was last updated. For information on what each Application Status means, visit: https://www.usajobs.gov/Help/how-to/application/status/.
You may preview the assessment questionnaire by clicking here: https://apply.usastaffing.gov/ViewQuestionnaire/11900158
Agency contact information
OPM Human Resources
Phone
202-606-9321
Email
jobs@opm.gov
Address
OPM Human Resources 1900 E St., NW Washington, DC 20415 US
Next steps
Based on your application and your responses to the application questionnaire, you may be presented with instructions on how to access the USA Hire system to complete the online assessments. The online assessments must be completed within 48 hours following the close of this announcement. You will have the opportunity to request a testing accommodation for the assessment should you have a disability covered under the Americans with Disabilities Act (ADA). Your assessment results will be kept on record for one year and used toward future positions for which you might apply that require the same assessments.
Once your online application is submitted you will receive a confirmation notification by email. Your application will be evaluated. You will receive another notification about the status of your application.
Once referred, you may be asked to complete a structured interview, written demonstration, and/or final interview. Deliberate attempts to falsify information may be grounds for not selecting you or for dismissing you from the position/agency during the probationary period.
We expect to make a job offer within 40 days after the closing date of the announcement. After making a tentative job offer, we will conduct a suitability/security background investigation.
- Fair and Transparent
The Federal hiring process is set up to be fair and transparent. Please read the following guidance.
- Equal Employment Opportunity (EEO) Policy
- Reasonable accommodation policy
- Financial suitability
- Selective Service
- New employee probationary period
- Signature and false statements
- Privacy Act
- Social security number request
Required Documents
To apply for this position, you must provide a complete Application Package which includes:
- Your Resume showing applicant’s name, email address, work schedule, hours worked per week, dates of employment and duties performed.
- Transcripts/Registration/License: If qualifying on education/position requires education, you must submit copies of your transcripts and if required for the position, submit an active, current registration/license
- Other supporting documents:
- Cover Letter, optional
- 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, Veterans Recruitment Appointment, and 30% Disabled Veteran 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, that lists you as authorized to accompany the Military member to the new duty permanent station; 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).
- Interchange Agreement with Other Merit Systems Eligible: Documentation of eligibility as listed in each individual interchange agreement.
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.
If you are relying on your education to meet qualification requirements:
Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education.
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
How to Apply
Please read the entire announcement and all the instructions before you begin an application. To apply for this position, you must complete the initial online application, to include submission of the required documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (EST) on 04/19/2023 to receive consideration. The application process is as follows:
- To begin the application process, click the Apply Online button.
- Answer the questions presented in the application and attach all necessary supporting documentation.
- Click the “Submit Application” button prior to 11:59pm (ET) on the announcement closing date.
- After submitting an online application, you will be notified whether or not you are required to take additional online assessments through the USA Hire Competency Based Assessment system. This message will be delivered to you both on screen and via email notification.
- If you are asked to take the USA Hire Competency Based Assessments, you will be presented with a unique URL to access the USA Hire system. Access to USA Hire is granted through your USAJOBS login credentials. Be sure to review all instructions prior to beginning your USA Hire Assessments. Note, set aside at least 3 hours to take these assessments; however, most applicants complete the assessments in less time. If you need to stop the assessments and continue at a later time, you can re-use the URL sent to you via email and also found on the “Additional Application Information” page that can be located in the application record in your USAJOBS account.
To update your application, including supporting documentation, at any time during the announcement open period by return to your USAJOBS account. There you will find a record of your application, the application status, and an option to “Update Application.” This option will no longer be available once the announcement has closed.
To verify the status of your application both during and after the announcement open period, log into your USAJOBS account, all of your applications will appear on the Welcome screen. The application record in your USAJOBS account provides an “Additional Application Information” page that provides information regarding the documentation you submitted and any correspondence we have sent related to this application. The Application Status will appear along with the date your application was last updated. For information on what each Application Status means, visit: https://www.usajobs.gov/Help/how-to/application/status/.
You may preview the assessment questionnaire by clicking here: https://apply.usastaffing.gov/ViewQuestionnaire/11900158
Agency contact information
OPM Human Resources
Phone
202-606-9321
jobs@opm.gov
Address
OPM Human Resources 1900 E St., NW Washington, DC 20415 US
Next steps
Based on your application and your responses to the application questionnaire, you may be presented with instructions on how to access the USA Hire system to complete the online assessments. The online assessments must be completed within 48 hours following the close of this announcement. You will have the opportunity to request a testing accommodation for the assessment should you have a disability covered under the Americans with Disabilities Act (ADA). Your assessment results will be kept on record for one year and used toward future positions for which you might apply that require the same assessments.
Once your online application is submitted you will receive a confirmation notification by email. Your application will be evaluated. You will receive another notification about the status of your application.
Once referred, you may be asked to complete a structured interview, written demonstration, and/or final interview. Deliberate attempts to falsify information may be grounds for not selecting you or for dismissing you from the position/agency during the probationary period.
We expect to make a job offer within 40 days after the closing date of the announcement. After making a tentative job offer, we will conduct a suitability/security background investigation.
Fair & Transparent
The Federal hiring process is set up to be fair and transparent. Please read the following guidance.
- Equal Employment Opportunity (EEO) Policy
- Reasonable accommodation policy
- Financial suitability
- Selective Service
- New employee probationary period
- Signature and false statements
- Privacy Act
- Social security number request