Health Insurance Specialist (Program Integrity)

Centers for Medicare and Medicaid Services
$76,671.00 - $128,956.00 / yr
United States, Illinois, Chicago
Nov 22, 2024
Duties Independently review and evaluate financial program payments, investigate fraud, waste, and abuse allegations, conduct program integrity reviews, and study financial systems. Analyze, develop, implement, and modify operating policy and procedures relating to program integrity. Provide technical assistance to stakeholders (e.g., Medicare, Medicaid, and/or private insurance that provide health care and drug services, and Providers), on CMS requirements. Prepare a variety of written products, including position papers and briefing materials for senior officials to use as background information on program integrity related activities. Requirements Conditions of Employment You must be a U.S. Citizen or National to apply for this position. You will be subject to a background and suitability investigation. May be required to serve a 1 year probationary period. Qualifications ALL QUALIFICATION REQUIREMENTS MUST BE MET BY THE CLOSING DATE OF THIS ANNOUNCEMENT. Your resume must include detailed information as it relates to the responsibilities and specialized experience for this position. Evidence of copying and pasting directly from the vacancy announcement without clearly documenting supplemental information to describe your experience will result in an ineligible rating. This will prevent you from receiving further consideration. In order to qualify for the GS-11, you must meet the following: You must demonstrate in your resume at least one year (52 weeks) of qualifying specialized experience equivalent to the GS-09 grade level in the Federal government, obtained in either the private or public sector), to include: Compiling data to assist in identifying fraud, waste, or abuse in the Medicare Part C and/or Part D program. Collaborating across organizational lines on investigations, audits, or oversight of program integrity contractors. Researching Medicare Part C and/or Part D statutes or guidance to report basic program issues. - OR - Substitution of Education for Experience: You may substitute education for specialized experience at the GS-11 level by possessing a Ph.D. or equivalent doctoral degree or 3 full years of progressively higher level graduate education leading to such a degree or equivalent doctoral degree or LL.M., if related to the position being filled. (TRANSCRIPTS REQUIRED AT TIME OF APPLICATION). - OR - Combination of Experience and Education: Only graduate education in excess of the amount required for the GS-09 grade level may be used to qualify applicants for positions at the grade GS-11. Therefore, only education in excess of a master's or equivalent graduate degree or 2 full years of progressively higher level graduate education leading to such a degree, may be used to combine education and experience. (TRANSCRIPTS REQUIRED AT TIME OF APPLICATION). TRANSCRIPTS are required to verify satisfactory completion of the educational requirement related to substitution of education for experience and combination of experience and education. Please see "Required Documents" section below for what documentation is required at the time of application. In order to qualify for the GS-12, you must meet the following: You must demonstrate in your resume at least one year (52 weeks) of qualifying specialized experience equivalent to the GS-11 grade level in the Federal government, obtained in either the private or public sector, to include: Reviewing Medicare Part C and/or Part D health insurance program vulnerability studies to detect fraud, waste, or abuse. Collaborating across organizational lines on Medicare Part C and/or Part D investigations, audits, or oversight of program integrity contractors. Researching Medicare Part C and/or Medicare Part D health care trends to identify how they may impact current policy. Substitution of Education for Experience: There is no substitution of education to meet the specialized experience requirement at the GS-12 grade level. Combination of Experience and Education: There is no combination of experience and education to meet the specialized experience requirement at the GS-12 grade level. 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. Click the following link to view the occupational questionnaire: Additional information Bargaining Unit Position: Yes - American Federation of Government Employees, Local 1923. Tour of Duty: Flexible Recruitment/Relocation Incentive: Not authorized Financial Disclosure: Not required Workplace Flexibility at CMS: This position has a regular and recurring reporting requirement to the CMS office listed in this announcement; however, CMS offers flexible working arrangements and allows employees the opportunity to participate in telework combined with alternative work schedules at the manager's discretion. This position *may* be authorized for telework. Telework eligibility will be discussed during the interview process. Supervisory positions must report a minimum 2 times per week and non-Supervisory positions must report a minimum of 2 times per pay period. The Interagency Career Transition Assistance Plan (ICTAP) and Career Transition Assistance Plan (CTAP) provide eligible displaced federal employees with selection priority over other candidates for competitive service vacancies. To be qualified you must submit the required documentation and be rated well-qualified for this vacancy. . A well-qualified applicant is one whose knowledge, skills and abilities clearly exceed the minimum qualification requirements of the position. Additional information about ICTAP and CTAP eligibility is on OPM's Career Transition Resources website at . 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. . 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 The following documents are REQUIRED: 1. Resume showing relevant experience; cover letter optional. Your resume must indicate your citizenship and if you are registered for Selective Service if you are a male born after 12/31/59. Your resume must also list your work experience and education (if applicable) including the start and end dates (mm/yyyy) of each employment along with the number of hours worked per week. For work in the Federal service, you must include the series and grade level for the position(s). Your resume will be used to validate your responses to the assessment tool(s). For resume and application tips visit: 2. CMS Required Documents (e.g., SF-50, DD-214, SF-15, etc.). Required documents may be necessary to be considered for this vacancy announcement. . Failure to provide the required documentation WILL result in an ineligible rating OR non-consideration. 3. College Transcripts. Although this position does not require a degree, you may substitute college credit in whole, or in part, for experience at specified grade levels. You must submit a copy of your transcript at the time of application in order to substitute your education for the required experience. If you do not submit a transcript, your education will not be considered in determining your qualifications for the position. You may submit an unofficial transcript or a list of college courses completed indicating course title, credit hours, and grades received. An official transcript is required if you are selected for the position. College Transcripts and Foreign Education: Applicants who have completed part or all of their education outside of the U.S. must have their foreign education evaluated by an accredited organization to ensure that the foreign education is comparable to education received in accredited educational institutions in the U.S. For a listing of services that can perform this evaluation, visit the website. This list, which may not be all inclusive, is for informational purposes only and does not imply any endorsement of any specific agency. PLEASE NOTE: A complete application package includes the online application, resume, transcripts (if qualifying through education substitution or a combination of education and experience) and CMS required documents. Please carefully review the full job announcement to include the "Required Documents" and "How to Apply" sections. Failure to submit the online application, resume, transcripts (if applicable) and CMS required documents, will result in you not being considered for employment. Additional Forms REQUIRED Prior to Appointment: If you are unable to apply online or need to fax a document you do not have in electronic form, view the following link for information regarding an . 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 . 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 Your complete application package, as described in the "Required Documents" section, must be received by 11:59 PM ET on 11/26/2024 to receive consideration. IN DESCRIBING YOUR WORK EXPERIENCE AND/OR EDUCATION, PLEASE BE CLEAR AND SPECIFIC REGARDING YOUR EXPERIENCE OR EDUCATION. We strongly encourage applicants to utilize the USAJOBS resume builder in the creation of resumes. Please ensure EACH work history includes ALL of the following information: Official Position Title (include series and grade if Federal job) Duties (be specific in describing your duties) Employer's name and address Supervisor name and phone number Start and end dates including month and year (e.g. June 2007 to April 2008) Full-time or part-time status (include hours worked per week) Determining length of general or specialized experience is dependent on the above information and failure to provide ALL of this information WILL result in a finding of ineligible. To begin, click Apply to access the online application. You will need to be logged into your USAJOBS account to apply. If you do not have a USAJOBS account, you will need to create one before beginning the application. Follow the prompts to select your resume and/or other supporting documents to be included with your application package. You will have the opportunity to upload additional documents to include in your application before it is submitted. Your uploaded documents may take several hours to clear the virus scan process. After acknowledging you have reviewed your application package, complete the Include Personal Information section as you deem appropriate and click to continue with the application process. You will be taken to the online application which you must complete in order to apply for the position. Complete the online application, verify the required documentation is included with your application package, and submit the application. To verify the status of your application, log into your USAJOBS account (), all of your applications will appear on the Welcome screen. The Application Status will appear along with the date your application was last updated. For information on what each Application Status means, visit: . This agency provides reasonable accommodation to applicants with disabilities. If you need a reasonable accommodation for any part of the application or hiring process, please send an email to hrinquiries@cms.hhs.gov. The decision to grant reasonable accommodation will be made on a case-by-case basis. Commissioned Corps Officers (including Commissioned Corps professionally boarded applicants) who are interested in applying for this position must send their cover letter and professional resume (not PHS Curriculum Vitae) to in lieu of applying through this announcement. The resume should specifically explain how you are qualified for this position and draw specific attention to your skills and experiences that demonstrates these qualifications. Also send any transcripts, licenses or certifications as requested in this announcement. *Please send all documents in 1 PDF file. In the subject line of your e-mail include only the Job Announcement Number. In the body of your e-mail include your current rank name and serial number. Failure to provide this information may impact your consideration for this position. Additional selections* may be made for similar positions across the Department of Health and Human Services (HHS) within the local commuting area(s) of the location identified in this announcement. By applying, you agree to have your application shared with interested selecting official(s) at HHS. Clearance of CTAP/ICTAP will be applied for similar positions across HHS. When the Department of Health and Human Services (HHS) completes its selections, the remaining list of qualified candidates may be shared with other federal agencies. You will have an opportunity to opt in if you would like your name, application material, and assessment results shared for consideration of employment with additional agencies. There is no guarantee of further consideration, and you can continue to explore other job opportunity announcements. Agency contact information CMS HR Inquiries Email Address Center for Program Integrity 7500 Security Blvd Woodlawn, MD 21244 US Next steps Once your online application is submitted, you will receive a confirmation notification by email. Your application will be evaluated to determine your eligibility and qualifications for the position. After the evaluation is complete, you will receive another email notification regarding the status of your application. Within 30 business days of the closing date,11/26/2024, you may check your status online by logging into your USAJOBS account (). We will update your status after each key stage in the application process has been completed. Fair & Transparent The Federal hiring process is set up to be fair and transparent. Please read the following guidance.