The Claims Management Program Analyst supports the Health Plan Management Unit by managing claims, provider recruitment, and compliance with healthcare standards. Responsibilities include liaising with stakeholders, ensuring claims accuracy, minimizing denials, and providing training. Requires healthcare claims expertise, program management skills, and adherence to HIPAA. Travel up to 15% may be required. This position is only open to USPHS officers and Call to Active Duty (CAD) candidates
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 illegal aliens or staff exiting the building (may require lifting, dragging, wheeling, or carrying someone who weighs significantly more than oneself).
DUTIES AND RESPONSIBILITIES: Serves in the capacity as a Claims Management Program Analyst; handles and assists program activities and policies related to claims management, and provider recruitment. Assumes leadership role as acting claims management program analyst lead when necessary. Serves as CMP representative between IHSC, third-party administrator, CBP components, and ICE ERO components in coordinating care and recruitment of off-site community provider for illegal aliens. Assist in developing, evaluating, and coordinating CMP related functions to ensure adherence to industry practices in eligibility verification, authorization of care, claims management denials and appeals to minimize adverse outcomes related to timely filing and maintaining a Provider Network to provide quality specialty care to illegal aliens. Duties include assisting in day-to-day managing, assessing, planning, developing, implementing, and evaluating assigned programs. Incumbent assists with reviews of policies. Incumbent ensures compliance with program regulations (e.g., appropriateness of health care and services based on regulatory, reimbursement requirements, evidence-based national care guidelines and evidence-based practices), maintains records per program policy, 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). Liaise regionally and, or, nationally with applicable stakeholders internal and external stakeholders (e.g., U.S. Customs and Border Patrol, third party administrator and off-site community providers) regarding medical claims processes, trainings, and principles. Provides guidance to the respective ICE custody, and medical staff members of facilities in which and ICE illegal aliens are held regarding ICE policies, reporting requirements, and applicable ICE detention standards. 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.