Health Insurance Specialist

ALL QUALIFICATION REQUIREMENTS MUST BE MET BY THE CLOSING DATE OF THIS ANNOUNCEMENT. Your resume (limited to no more than 2 pages) 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-09, 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-07 grade level in the Federal government, obtained in either the private or public sector, to include: Gathering and compiling financial program payment data, provider enrollment records, or related documentation to support investigations or inquiries involving fraud, waste, or abuse (FWA) in a health insurance program (e.g., Medicare, Medicaid, or Marketplace); AND Supporting investigations, audits, or compliance activities related to health insurance programs through collaboration with internal teams, external agencies, contractors, or oversight bodies; AND Analyzing federal health care statutes, regulations, and program integrity guidance to identify compliance concerns, program integrity issues, or policy matters related to provider enrollment or health insurance program operations, and preparing findings for reporting purposes. - OR - Substitution of Education for Experience: You may substitute education for specialized experience at the GS-09 level by possessing a Master's or equivalent graduate degree or 2 full years of progressively higher level graduate education leading to such a degree or LL.B. or J.D., if related to the position being filled. - OR - Combination of Experience and Education: Only graduate education in excess of the amount required for the GS-07 grade level may be used to qualify applicants for positions at the grade GS-09. Therefore, only education in excess of 1 full year of graduate level education may be used to combine education and experience. TRANSCRIPTS are required to verify satisfactory completion of the educational requirement related to the substitution of education for experience and the combination of experience and education. Please refer to the "Required Documents" section below for the documentation required at the time of application. 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: Reviewing financial program payment data and provider enrollment records to identify potential indicators of fraud, waste, or abuse (FWA) in a health insurance program (e.g., Medicare, Medicaid, or Marketplace) and applying established analytical methods, protocols, and frameworks to assess FWA issues at the operational level; AND Coordinating with internal teams, external agencies, contractors, and oversight bodies to support investigations, audits, or compliance and oversight activities related to health insurance programs, including preparing factual summaries and case documentation in support of multi-agency efforts; AND Researching and applying federal health care statutes, regulations, or program integrity guidance to analyze and report on compliance concerns or program integrity issues related to provider enrollment or health insurance program operations. - 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. - 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 degree or its equivalent, or 2 full years of progressively higher-level graduate education leading to such a degree, may be used to combine education and experience. TRANSCRIPTS are required to verify satisfactory completion of the educational requirement related to the substitution of education for experience and the combination of experience and education. Please refer to the "Required Documents" section below for the documentation required at the time of application. 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: https://apply.usastaffing.gov/ViewQuestionnaire/12969735 This position is located in the Department of Health & Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), Center for Program Integrity (CPI), Provider Enrollment & Oversight Group (PEOG). As a Health Insurance Specialist, GS-0107-9/11, you will serve as the focal point for all Medicare provider and supplier enrollment compliance functions, including identifying and reporting provider enrollment related vulnerabilities that may indicate fraud, waste, or abuse.