Health Insurance Specialist

Centers for Medicare & Medicaid Services•Woodlawn, MD

12d

About The Position

The Health Insurance Specialist, GS-0107-13, serves in the Department of Health & Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), Office of Financial Management, Payment Accuracy and Reporting Group (PARG). The position is CMS’s primary focal point for functional administration and oversight of the Comprehensive Error Rate Testing (CERT) Program and for internal and external reporting of CMS Medicare Fee-for-Service (FFS) improper payment activities. The specialist provides policy analysis and technical guidance on the Payment Integrity Information Act (PIIA) and Medicare FFS improper payment measurement, helping ensure consistent interpretation of legislation, regulations, coverage policies, and billing requirements. The role guides CMS contractors and Medicare Administrative Contractors in implementing program policies, reviewing improper payment reports and reduction strategies, and educating stakeholders about compliance and reporting requirements. The specialist develops, implements, and evaluates initiatives to improve operational efficiency, identify causes of improper payments, mitigate risks, and recommend policy and procedural improvements. The work also includes studies and program evaluations to assess payment integrity, identify trends, validate analytical models, and evaluate the feasibility of large-scale reviews and audits. The specialist prepares regulations, guidance, briefing materials, congressional reports, and financial reporting content; advises CMS leadership; represents the agency before stakeholders; and coordinates responses to complex program inquiries.

Requirements

U.S. citizenship or national status.
At least one year (52 weeks) of specialized experience equivalent to GS-12 in the Federal government, obtained in the public or private sector.
Experience supporting improper payment measurement contractors on Medicare FFS policies and requirements.
Experience communicating Medicare FFS coverage policies for items and services eligible for payment to the public or medical professionals.
Experience educating providers, beneficiaries, and stakeholders on Medicare FFS compliance, billing, reporting, or other operational matters.
Experience preparing briefing materials or reports, such as contributing to the Payment Integrity Report section of the annual Agency Financial Report and compiling supplemental improper payment data for oversight and transparency.
Qualifications must be met within 30 days of the announcement closing date.
A resume of no more than two pages with detailed information documenting relevant responsibilities and specialized experience.
Time-in-grade requirements apply to qualifying current or former federal employees.
Subject to background and suitability investigation.
Males born after December 31, 1959, must be registered or exempt from Selective Service.
A one-year probationary period may be required.
Federal salary payments must be made by direct deposit.
If selected, identity and employment eligibility documents will be verified through DHS E-Verify.

Responsibilities

Provide expert policy analysis and technical guidance on PIIA and the Medicare FFS improper payment measurement program.
Ensure consistent interpretation of legislation, regulations, coverage policies, and billing requirements.
Guide CMS contractors and Medicare Administrative Contractors in implementing program policies.
Review improper payment reports and reduction strategies.
Educate stakeholders on compliance and reporting requirements.
Develop, implement, and evaluate initiatives to improve operational efficiency and identify root causes of improper payments.
Mitigate risks and recommend policy and procedural improvements.
Conduct special studies, comparative analyses, and program evaluations to assess payment integrity and identify emerging trends.
Validate analytical models and determine the feasibility of large-scale reviews and audits.
Prepare regulations, sub-regulatory guidance, briefing materials, congressional reports, and financial reporting content.
Advise CMS leadership and represent the agency before stakeholders.
Coordinate responses to complex program inquiries.