The Claims Management and U.S. Customs and Border Protection Program Analyst supports DHS ICE Health Service Corps' Health Plan Management Unit. Responsibilities include claims adjudication, provider recruitment, training, fraud prevention, and liaison duties with CBP, HSI, and third-party administrators. 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.
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 ¼ 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)
DUTIES AND RESPONSIBILITIES: Serves as one of the primary points of contact and liaison to the third-party administrator on issues relating to medical claims processing and resolution and provider reimbursement. Serves as one of the primary points of contact and liaison to the U.S. Customs and Border Patrol, Office of Field Operations (OFO) and Homeland Security Investigations (HSI). Provides oversight and consultation while reviewing, approving, denying, and adjudicating Medical Payment Authorization Requests for reimbursable healthcare services submitted by CBP, OFO, and HSI. Requests MedPARs for reimbursable health care services and medical claims review. Collaborates with the Claims Management Program to reconcile and resolve denied community provider claims and/or appeals. Provides oversight and consultation to CBP for recruitment and enrollment of providers into the IHSC provider network. Liaise regionally and, or, nationally with applicable internal and external stakeholders (CBP, and third-party administrator, off-site community providers) regarding medical claims processes, trainings, and principles. Provides orientation, training, and guidance to CBP and ICE custody staff responsible for overseeing individuals detained by CBP and ICE. This includes ensuring adherence to ICE policies, reporting requirements, and applicable ICE detention standards. Identifies potential areas for improvement in the managed care delivery system that warrants re-engineering to create efficiencies, marketing and increase cost containment controls, and ensure the provision of necessary and appropriate health care. Supports systems and mechanisms to identify potential fraud, waste and abuse. Evaluates, assesses, and recommends reimbursement methodologies and procedures. Assists third-party administrator when necessary in coordinating and obtaining information pertaining to Medical Provider Authorization Requests (MedPARs) or eligibility in the alien tracking system. Develops specific goals and plans to prioritize, organize, and accomplish positive outcomes. TDY as needed to provide clinical care support at IHSC-staffed detention facilities with critical staffing needs. Travel may be required- minimal (<15%) Performs other duties as assigned.