This position is located at various locations in the Southwest Region of the Indian Health Service. The purpose of the position is to determine patient's eligibility, defining and interpreting regulations and guidelines and maintaining records. Employee identifies and assists patients who may be eligible for coverage by third party resources. Subject matter expert in determining patient's eligibility and advise others as needed.
To qualify for this position, your resume must state sufficient experience and/or education, to perform the duties of the specific position for which you are applying. 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; social). You will receive credit for all qualifying experience, including volunteer and part time experience. You must clearly identify the duties and responsibilities in each position held and the total number of hours per week. MINIMUM QUALIFICATIONS, GS-0962-05: Your resume must demonstrate at least one (1) year of specialized experience equivalent to at least the GS-04 grade level in the Federal service obtained in either the private or public sector performing the following type of work and/or tasks: Examples include: Assist individuals in completing forms, provide information to the public, conduct personal or telephone interviews by utilizing screening and interviewing methods, verify patient eligibility for benefits, review claims and review records; establish and maintain contact with internal/external entities, local and regional agencies, programs and offices in order to obtain relevant information. OR Possess (4) years of education above the high school level. NOTE: One year of full-time academic study is defined as 30 semester hours, 45 quarter hours, or the equivalent in a college or university, or at least 20 hours of classroom instruction per week for approximately 36 weeks in a business, secretarial, or technical school. (TRANSCRIPTS REQUIRED) OR Possess a combination of education and experience that when combined fully meet the minimum qualifications for this position. The total percentage must equal at least 100 percent to qualify an applicant for GS-05 grade level. (TRANSCRIPTS REQUIRED) MINIMUM QUALIFICATIONS, GS-0962-06: Your resume must demonstrate at least one (1) year of specialized experience equivalent to at least the GS-05 grade level in the Federal service obtained in either the private or public sector performing the following type of work and/or tasks: Examples include: Assist individuals in completing forms, provide information to the public, conduct personal or telephone interviews by utilizing screening and interviewing methods, verify patient eligibility for benefits, review claims and review records; establish and maintain contact with internal/external entities, local and regional agencies, programs and offices in order to obtain relevant information; monitor pending actions. MINIMUM QUALIFICATIONS, GS-0962-07: Your resume must demonstrate at least one (1) year of specialized experience equivalent to at least the GS-06 grade level in the Federal service obtained in either the private or public sector performing the following type of work and/or tasks: Examples include: Assist individuals in completing forms, provide information to the public, conduct personal or telephone interviews by utilizing screening and interviewing methods, verify patient eligibility for benefits, review claims, review records, establish and maintain contact with internal/external entities, local and regional agencies, programs and offices in order to obtain relevant information; monitor pending actions, interpret and explain rules and regulations for a variety of alternate resources. MINIMUM QUALIFICATIONS, GS-0962-08: Your resume must demonstrate at least one (1) year of specialized experience equivalent to at least the GS-07 grade level in the Federal service obtained in either the private or public sector performing the following type of work and/or tasks: Examples include: Assist individuals in completing forms, provide information to the public, conduct personal or telephone interviews by utilizing screening and interviewing methods, verify patient eligibility for benefits, review claims, review records, establish and maintain contact with internal/external entities, local and regional agencies, programs and offices in order to obtain relevant information. monitor pending actions, interpret and explain rules and regulations for a variety of alternate resources, compile and write reports, research records or guidelines; advise individuals on all aspects of benefits. Time In Grade Federal employees in the competitive service are also subject to the Time-In-Grade Requirements: Merit Promotion (status) candidates must have completed one year of service at the next lower grade level. Time-In-Grade provisions do not apply under the Excepted Service Examining Plan (ESEP). You must meet all qualification requirements within 30 days of the closing date of the announcement.
Eligibility Determination: Receives notification and referrals for referred care through hard copy or the automated referred care system. Enters or edits all referrals. Ensures accurate data entry in order to retrieve meaningful reports. Verifies and determines patient's eligibility for Medicare, Medicaid, Private Insurance, VA or other potential alternate resources as appropriate, which are available and accessible to the individual. Develops and implements procedural guides; compiles and interprets various alternate resource references and guides. Researches matters thoroughly based on appropriate regulations or other mandatories prior to rendering work product. Analyzes the facts of individual cases and researches regulations and guidelines, which are relevant to the facts of the case. Determines the sufficiency of the documentation submitted for consideration. Initiates action with appropriate office(s) in order to obtain the required documentation or information (i.e. supportingdocuments and evidence). Issuance of documents: Ensures that funds are available prior to issuance of obligating documents on behalf of the government. Provides forecasting of weekly document control register balances after each week's obligations have been completed to ensure funds are expended in accordance within spending plans. Fiscal Management Activities: Maintains complete fund control records for health services funds allotted. Ensures the presence of accurate information, monitors activities and records pertaining to the fiscal management of funds. Identifies problem areas and recommends corrective action. Reconciles the commitment register to the automated financial system. Ensures and maintains internal (Service Unit) fiscal controls by utilizing appropriate fiscal and accounting codes on funds being obligated. Administrative Support: Issues correspondence to patients, health care providers and other agencies regarding eligibility, policy and regulations, including letters of denial of payment where the requirements of the program are not met. Maintains program files including letters of denials with all backup material for reason for denial, elective procedures, etc. Completes timely response to appeals through review of case files and all supporting information. Case Management: Tracks all referrals to include those referrals to other facilities to support the Case Management activities and continuity of care efforts. Participates in the weekly Case Management meetings, takes minutes and prepares the minutes for record and reporting purpose. Researches and follow up with facilities on weekly basis for current medical status and costs to determine whether the case will be a Catastrophic Health Emergency Fund (CHEF) case.