Claims Examiner

Veterans Health Administration • Lakewood, CO

4d • Onsite

About The Position

This Claims Examiner position is in the Specialty Programs Department, Veteran and Family Member Programs (VFMP), within the Veterans Health Administration (VHA), and is located in Lakewood, Colorado. It is not a virtual position; applicants must live within or be willing to relocate within commuting distance of the duty location. Ad hoc telework may be authorized, with eligibility discussed during the interview. The work schedule will also be discussed during the interview.

The role processes foreign medical claims using a complex manual system without automation or artificial intelligence assistance. The Claims Examiner uses extensive knowledge of diagnostics and medical services, performs complex diagnostic and procedure coding, and independently interprets program laws and regulations to adjudicate claims. The position also involves researching medical claims and responding to Congressional and White House inquiries. Recruitment and relocation incentives are not authorized, and a Critical Skills Incentive has not been approved.

Requirements

• U.S. citizenship.
• At least one year of specialized experience equivalent to at least the GS-7 grade level in Federal service.
• Specialized experience processing medical claims and applying comprehensive knowledge of provider relations, reimbursement methods, coordination of benefits, and medical cost-recovery practices.
• Document experience on the resume, including job title, duties, month and year start/end dates, and hours worked per week.
• Complete the required application, questionnaire, and online assessment.
• Subject to a background/security investigation.
• Complete the online onboarding process and provide acceptable identification for pre-employment requirements.
• Participation in the seasonal influenza vaccination program is required for Department of Veterans Affairs Health Care Personnel.
• Serve a one-year probationary period.

Responsibilities

• Process foreign medical claims on a complex manual system without automation or artificial intelligence assistance.
• Use extensive knowledge of diagnostics and medical services.
• Perform complex diagnostic and procedure coding.
• Independently apply and interpret program laws and regulations to adjudicate medical claims.
• Examine, develop, and evaluate documentation related to claims submitted for payment.
• Research whether conditions treated on medical claims are service-connected or associated with or aggravated by a Veteran's listed service-connected conditions.
• Use medical reference books, medical dictionaries, online medical websites, and coding software to research complex medical claims.
• Convert foreign currency to its equivalent amount in United States dollars.
• Apply expert understanding of the laws and regulations governing the FMP and technical aspects of processing FMP claims to research and respond to Congressional and White House inquiries.
• Perform other duties as assigned.

Benefits

• Federal employee benefits package; specific benefits depend on position type and should be confirmed with the hiring agency.
• Potential credit toward annual leave accrual based on prior work or military service, subject to request and approval before appointment.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed