Claims Examiner

Summary

This position is in the Specialty Programs Department, Veteran and Family Member Programs (VFMP), within the Veterans Health Administration (VHA). The position is in Lakewood, Colorado.

Duties

THIS IS NOT A VIRTUAL POSITION, YOU MUST LIVE WITHIN OR BE WILLING TO RELOCATE WITHIN A COMMUTABLE DISTANCE OF THE DUTY LOCATION Major duties and responsibilities include: Processing foreign medical claims on a complex manual system, without automation or artificial intelligence assistance Utilizing an extensive knowledge of diagnostics and medical services Performing complex diagnostic and procedure coding Independently applying and interpreting laws and regulations set forth in the program policy to adjudicate medical claims Examining, developing, and evaluating relevant documentation related to claims submitted for payment Independently performing research to determine whether conditions treated on medical claims are service-connected or associated with or aggravated by the Veteran's listed service-connected condition(s) Utilizing medical reference books, medical dictionaries, online medical websites, coding software, etc. in performing research related to complex medical claims Converting foreign currency to the equivalent amount in United States dollars Applying expert understanding of the laws and regulations governing the FMP and all technical aspects of processing FMP claims to perform research and responds to Congressional and White House inquiries. Performing other duties as assigned Work Schedule: To be discussed during interview Recruitment & Relocation Incentives: Not authorized Critical Skills Incentive (CSI): Not approved Telework: This position may be authorized for ad hoc telework. Telework eligibility will be discussed during the interview process. Ad hoc is defined as occasional, non-recurring telework. Requirements

You must be a U.S. Citizen to apply for this job To be considered for this position, you must complete all required steps in the process. In addition to the application and questionnaire, this position requires an online assessment. The online assessment measures critical general competencies required to perform the job. Subject to background/security investigation Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP) - See "Required Documents" below for details. As a condition of employment for accepting this position, you will be required to serve a 1-year probationary period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service. Upon completion of your probationary, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest. Qualifications

To qualify for this position at the GS-8 level, you must have: At least one (1) full year of specialized experience that equipped you with the knowledge, skills, and abilities to successfully perform the duties of this position (Claims Examiner). To be creditable, specialized experience must have been equivalent to at least the next lower grade level (GS-7) in the Federal service. Specialized experience is defined as experience processing medical claims and applying comprehensive knowledge of provider relations, reimbursement methods, coordination of benefits, and medical cost-recovery practices. Note: Experience must be fully documented on your resume and must include job title, duties, month and year start/end dates AND hour worked per week. For more information on these qualification standards, please visit the United States Office of Personnel Management's website at https://www.opm.gov/policy-data-oversight/classification-qualifications/general-schedule-qualification-standards/.

Education

There is no educational substitution at this grade level. How You Will Be Evaluated

Your qualifications will be evaluated based on your application materials (e.g., resume, supporting documents), your responses on the application questionnaire, and your responses to all assessments required for this position. You will be assessed on the following competencies (knowledge, skills, abilities, and other characteristics): Attention to Detail Customer Service Decision Making Flexibility Integrity/Honesty Interpersonal Skills Learning Reading Comprehension Self-Management Stress Tolerance Teamwork Your experience must be fully documented on your resume and must include job title, duties, month and year start/end dates AND hours worked per week. A full year of work is considered to be 35-40 hours of work per week. Part-time experience will be credited on the basis of time actually spent in appropriate activities. Applicants wishing to receive credit for such experience must indicate clearly the nature of their duties and responsibilities in each position and the number of hours a week spent in such employment. IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE WILL NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Overstating your qualifications and/or experience in your application materials or application questionnaire may result in your removal from consideration. Cheating on the online assessment may also result in your removal from consideration. Candidates who apply under "All U.S. Citizens" announcements will be rated and ranked using Category Rating procedures. Qualified candidates will be assigned to a quality category. The categories are defined as follows: Best qualified - Applicants possessing the type and quality of experience that substantially exceeds the minimum qualifications Very Highly Qualified - Applicants possessing the type and quality of experience that exceeds, to a very considerable extent, the minimum qualifications Highly Qualified - Applicants possessing the type and quality of experience that exceeds, to a considerable extent, the minimum qualifications Well qualified - Applicants possessing the type and quality of experience that marginally exceeds the minimum qualifications of the position and who demonstrate average proficiency in most of the critical competencies Qualified - Applicants possessing the type and quality of experience that meets the minimum qualifications Application of Veterans' Preference: Category rating and selection procedures place those with veteran's preference above non-preference eligibles within each category. Preference eligible applicants that meet the eligibility and qualification requirements and who have a compensable service-connected disability of at least 10 percent are listed in the highest quality category (except when the position being filled is scientific or professional at the GS-09 grade level or higher). 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; religions; 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. Other Information

Reasonable Accommodation (RA) Requests: If you believe you have a disability (i.e., physical or mental), covered by the Rehabilitation Act of 1973 as amended that would interfere with completing the USA Hire Competency Based Assessments, you will be granted the opportunity to request a RA in your online application. Requests for RA for the USA Hire Competency Based Assessments and appropriate supporting documentation for RA must be received prior to starting the USA Hire Competency Based Assessments. Decisions on requests for RA are made on a case-by-case basis. If you meet the minimum qualifications of the position, after notification of the adjudication of your request, you will receive an email invitation to complete the USA Hire Competency Based Assessments, based on your adjudication decision. You must complete all assessments within 48 hours of receiving the URL to access the USA Hire Competency Based Assessments if you received the link after the close of the announcement. To determine if you need a RA, please review the Procedures for Requesting a Reasonable Accommodation for Online Assessments. Receiving Service Credit for Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed. This job opportunity announcement may be used to fill additional vacancies. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act. The Interagency Career Transition Assistance Plan (ICTAP) and Career Transition Assistance Plan (CTAP) provide eligible displaced Federal competitive service employees with selection priority over other candidates for competitive service vacancies. To be qualified you must submit appropriate documentation and be found well-qualified (have a final rating of 80 or more before any Veterans preference points) for this vacancy. Information about ICTAP and CTAP eligibility is on OPM's Career Transition Resources website at http://www.opm.gov/policy-data-oversight/workforce-restructuring/employee-guide-to-career-transition/.