Claims Management Program Analyst (O-5 Billet) Non-Supervisory

Summary

Serves as a Claims Management Program Analyst for IHSC, overseeing medical claims operations, provider network enrollment, TPA coordination, claims resolution, reporting, and stakeholder support. Provides program analysis, guidance, and liaison support to ensure timely claims adjudication and compliance with healthcare policies. This position is only open to USPHS officers who are currently IHSC employees. USPHS Call to Active Duty (CAD) candidates are not eligible for this position.

Duties

DUTIES AND RESPONSIBILITIES: Serves in the capacity of claims Management Program Analyst and subject matter expert (SME) in the oversight of program activities and policies related to medical claims and IHSC provider recruitment. Serves as one of the primary points of contact and liaison to the claims processing third-party administrator (TPA) on issues related to medical claims processing, denials, appeals provider reimbursement, provider recruitment, and resolutions. Assumes leadership role as Acting Claims Management Program lead when necessary. Duties include day-to-day managing, assessing, planning, developing, budgeting, implementing, and evaluating assigned programs. Incumbent ensures compliance with program regulations (e.g., appropriateness of health care and services based on regulatory, reimbursement requirements, maintains records per program policy, chairs meetings, coordinates and, or, manages programs within immediate organizational component. Communicates and collaborates with individuals or groups from outside the agency, including consultants and contractors. Work purpose is primarily to collaborate; supply advice; explain, interpret and seek support for methods, policies and programs; or render a service of a moderately complex nature requiring a moderate amount of explanation and tact (e.g., support for budget). Provides oversight and consultation for recruitment and enrollment of providers into the IHSC provider network. Liaises regionally and, or, nationally with applicable stakeholders internal and external stakeholders [e.g., Customs and Border Patrol, Office of Field Operations, Homeland Security Investigation (HSI) and third-party claims vendor] regarding claims processes, trainings, and principles. This requires contact via virtual conferences and/or telephone dialogue on a routine basis. Provides orientation and guidance to the respective ICE, custody, and medical staff members of facilities in which ICE patients are held regarding CMP processes with related ICE policies. Serves as Claims Management Program SME for IHSC's TPA claims processor. Liaises as the SME with IHSC staff and the TPA claims processor on issues relating to claims, medical claims processing/resolution, provider reimbursement, and provider recruitment/enrollment. Coordinates and collaborates with internal and external stakeholders, including community providers, CBP stations/sectors, HSI, non-IHSC facilities and IHSC facilities to administratively manage and adjudicate medical claims to meet the IHSC mission. Assists TPA and stakeholders when necessary, in coordinating and obtaining information pertaining to referrals, authorization or information pertaining to eligibility in the alien tracking system. Coordinates the purchase or rental of durable medical equipment for detainees in ICE custody. Creates and submits various reports for CMP Administrator, IHSC leadership as well as external stakeholders. Develops specific goals and plans to prioritize, organize, and accomplish positive outcomes with chain of command for business plans and strategic plans. Judgmental failure can result in ineffective or inappropriate use of resources and delays in meeting public health objectives of the office or agency. This may also impair the development of systems, affect the work of subordinate employees, and compromise the delivery of other administrative and personnel services. Travel may be required - estimated 15%. Travels TDY as needed to provide clinical care support at IHSC-staffed detention facilities with critical staffing needs. Performs other duties and responsibilities as assigned. Qualifications

PHYSICAL DEMANDS: Sitting and/or standing for extended periods of time [6-8 Hours]. Performing repeated bending motion. Average manual dexterity for computer operation. Phone use for extended periods of time. Required to walk unaided at a normal pace for up to 5 minutes and maintain balance. Required to jog/fast walk up to 1⁄4 mile. Required to perform CPR/emergency care standing or kneeling. Must have the ability to assist sick, injured, or aging detainees or staff exiting the building (may require lifting, dragging, wheeling, or carrying someone who weighs significantly more than oneself).

Education

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES: Incumbent must possess a bachelor's degree in healthcare related field (master's degree preferred) with a minimum of five 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, health insurance or medical claims is preferred. 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. Incumbent must possess at minimum, a Level II COR 40-hour course certificate or must obtain after one year of hire through the Defense Acquisition University (DAU) and Federal Acquisition (FAI) Cornerstone OnDemand (CSOD) online comprehensive learning platform. Program Management experience preferred. Well-developed knowledge and skills in the areas of claims management, health insurance and medical necessity. Preferably a minimum of one year within IHSC. 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 and Adobe. How You Will Be Evaluated

We will review your resume and supporting documentation to ensure you meet the minimum qualification requirements. You may be selected for an interview at the hiring authority's discretion. You will be notified of selection or non-selection. Other Information

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), Healthcare Compliance Division, Health Plan Management Unit (HPMU). The incumbent reports directly to the IHSC Claims Management Program Lead. This is a non-supervisory position. The HPMU Claims Management Program (CMP) manages operations of a provider network, claims adjudication processes and IHSC's claim processing third-party administrator (TPA). The CMP collaborates with the TPA claims processor, IHSC's Credentialing and Privileging Unit and off-site community providers to complete enrollment processes and establish letters of understanding with IHSC. CMP works jointly with internal and external stakeholders to meet mission initiatives, maintain a provider network and achieve timely adjudication of claims. IHSC is committed to providing the necessary medical intervention for aliens to reduce global disease and support the safe apprehension, enforcement and removal of aliens involved in immigration proceedings. In Fiscal Year (FY) 2025, IHSC provided medical services to more than 171,000 detained aliens housed in 17 facilities throughout the nation. In FY 2025, IHSC oversaw compliance with health related standards for over 266,000 detained aliens housed in 217 non-IHSC-staffed facilities, totaling over 50,700 beds. IHSC Headquarters provides guidance and support to IHSC-staffed facilities. While IHSC does not directly provide medical services in non-IHSC-staffed facilities, IHSC audits the facilities' compliance with national detention standards, as required by each facility's contract with ICE. SUPERVISORY CONTROLS: The CM Program Analyst works under the supervision of the IHSC HPMU Claims Management Program Lead. The incumbent plans and organizes his/her own work, determines the sequence of assignments, selects and develops methods, and seeks assistance from experts only rarely. Assignments are usually long-term, recurring, or broadly defined. Work is reviewed for feasibility, compatibility with other work, and effectiveness in meeting expected results.