Medical Claims Review Manager jobs in Virginia Beach, VA

PHYSICAL DEMANDS:

• Incumbent must possess a minimum of three years of professional experience relevant to the officer's category. Of the total professional experience, officer must possess at least two years of experience related to management, administration, or evaluation of public health programs. Healthcare management, finance or medical claims is preferred.

• Qualifying degree for the officer's category from an accredited institution

• If the incumbent holds a clinical license, it is the responsibility of the incumbent to fulfill the obligation(s) of their licensing or certifying body to maintain status. The agency may require the incumbent performs clinical activities with the scope of clinical license in times of critical needs within the agency. If in a clinical discipline and as directed and approved by his/her supervisors, the incumbent may perform clinical duties of their profession in Federal health care facilities. Such direction is documented via a memorandum of assignment and is filed in the eOPF.

• Well-developed knowledge and skills in the areas of claims management and medical necessity.

• Knowledge of medical, administrative, ethical, and legal requirements and standards related to healthcare delivery.

• 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.

• 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.

This position is located within the Department of Homeland Security (DHS), Immigration and Customs Enforcement (ICE), Enforcement and Removal Operations (ERO), ICE Health Service Corps (IHSC), Office of Deputy Assistant Director for Healthcare Compliance, Office of Health Plan Management Unit (HPMU). The incumbent reports directly to the IHSC Medical Claims Program Manager (MCPM). This is a non-supervisory position.

HPMU focuses on medical claims program through the governance of a provider network, claims adjudication and utilization management. HPMU collaborates with the Veterans Affairs Financial Services Center (VAFSC), a third-party medical claims administrator, and offsite providers to establish letters of understanding with IHSC. HPMU also works jointly with IHSC stakeholders: pharmacy; dental; the Behavioral Health Unit; the Medical Case Management Unit; and IHSC headquarters to meet mission initiatives. HPMU trains field medical coordinators, managed care coordinators and referral coordinators to improve processes related to the recruitment and retention of outside providers and claims process workflows to decrease claims denials and increase the number of paid claims.

In Fiscal Year (FY) 2021, the ICE Health Service Corps (IHSC) administered and managed a health care system that provided direct care to over 88,000 detainees housed at 21 designated facilities throughout the nation, to include medical, dental, mental health care, and public health services. Oversaw health care for over 169,000 detainees housed in 150 non-IHSC-staffed facilities, totaling over 53,000 beds. In FY 2021, there were a total of 205,242 individuals in ICE custody, with an average length of stay of 37 days. IHSC also directly supports ICE field office directors on medical issues within their area of responsibility. IHSC executed a budget that approached $316M in FY 2021.


SUPERVISORY CONTROLS
The Claims Management Program Analyst works under the supervision of the IHSC HPMU Supervisory Regional Claims Management Program Analyst.

Assignments are usually of a long-term, recurring, or broadly defined nature. Officer plans, and organizes own work, determines sequence of assignments, selects, and develops methods and seeks assistance from experts only rarely. Work is reviewed feasibility, compatibility with other work, and effectiveness in meeting requirements or expected results and objectives. Guidelines may be applicable to some but not all parts of assignment and may contain some inconsistencies and be partially unconfirmed. Selection and adaption from available possibilities involving a moderate amount of modifications and innovation is required. The officer uses judgement in interpreting and adapting guidelines such as policies, regulations, training precedents and work direction for application to specific cases.

The officer analyses results and recommends changes in guidelines and program policies. Innovations and modifications to accepted procedures must be approved and clearly documented. The officer keeps the supervisor informed of the status on projects and consults with him/her on any significant problems encountered.

• Cover Letter/Letter of Interest. Please include location preference here.

• Degrees. (Place under "Diploma/GED")

• Professional license. (If applicable)

• Additional professional certificates. (If applicable)

• Three professional references. (i.e., name, title and contact information)

• CV - e.g., relevant experience, education, training. (Place under "Resume")

• A copy of your Certificate of Investigation (located in your eOPF).

• For IHSC USPHS officers only, a copy of your current Service Remaining Requirements Agreement.

• Indicate if you have an Assignment Pay (AP) Agreement and the date of the end of your AP Agreement.

• Cover letter/Letter of Interest. Please include location preference here.

• Degrees. (Place under "Diploma/GED")

• Professional license. (If applicable)

• Additional professional certificates. (If applicable)

• Three professional references (i.e., name, title, and contact information)

• CV - e.g., relevant experience, education, training. (Place under "Resume")

• U.S. Public Health Service - Appointment Board Decision Letter/Email.

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.