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Summary This position is located with the Division of Purchased/Referred Care at the Gallup Indian Medical Center in Gallup, NM. The purpose of the position is to administer the provision of Purchased/Referred Care in compliance with regulatory requirements to determine patient's eligibility, defining and interpreting regulations and guidelines and maintaining records. Employee identifies and assists patients who may be eligible for coverage by third party resources. Responsibilities Performs prescreening process for potential eligibility and gathers pertinent information utilized to determine eligibility and potentially eligibility for alternative resources. Verifies and determines patient's eligibility. Compiles and interprets various alternate resource references and guides. Initiates medical authorizations and denial of service for inpatient/outpatient/ancillary medical services for eligible Indian Health Services (IHS) beneficiaries. Ensures and maintains internal (Service Unit) fiscal controls by utilizing appropriate fiscal and accounting codes on funds being obligated. Answers technical correspondence, compiles information and prepares periodic and special reports. Issues correspondence to patients, health care providers and other agencies regarding eligibility. Maintains program files including letters of denials with all backup material for reason for denial, elective procedures, etc. Tracks all referrals to non-IHS facilities to include those referrals to other IHS facilities to support the Case Management activities and continuity of care efforts Requirements Conditions of Employment Selectee may be subject to a probationary/trial period ESEP appointees typically serve a two year trial period U.S. Citizenship is required Selective Service Registration is required for males born after 12/31/1959 This is a designated position covered by Public Law 101-630, requiring contact or control over Indian children. Due to this requirement, the agency must ensure that persons hired for these positions have not been found guilty of or pleaded nolo contendere or guilty to certain crimes. Confidential Financial Disclosure Form required. IHS Selectees that will work in an IHS health care facility may be subject to Employee Health Policies related to Measles and Rubella, and seasonal influenza immunizations. Vaccine exemption requests may be available according to the National and/or Service Unit guidance. Successfully pass the E-Verify employment verification check. To learn more about E-Verify, including your rights and responsibilities, visit www.dhs.gov/E-Verify/. You will need to set up direct deposit so we can pay you. Background Investigation: If you are selected for this vacancy, you must undergo a pre-employment fingerprint check and background investigation. Fingerprint results and background investigation documentation must be cleared prior to hire. After you begin your employment, your continued employment is contingent upon the outcome of a complete background investigation as determined by the sensitivity level of your position. The investigation must find that you are suitable for Federal employment in your position. If you are found not suitable, you will be terminated after you begin work. If you make a false statement in any part of your application, you may not be hired; you may be fired after you begin work; or subject to possible criminal charges. You may be subject to a credit check as a part of the background investigation process. Qualifications To qualify for this position, your resume must state sufficient experience and/or education, to perform the duties of the specific position for which you are applying. 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; social). You will receive credit for all qualifying experience, including volunteer and part time experience. You must clearly identify the duties and responsibilities in each position held and the total number of hours per week. MINIMUM QUALIFICATIONS: GS-06: Your resume must demonstrate at least one (1) year of specialized experience equivalent to at least the next lower grade level in the Federal service obtained in either the private or public sector performing the following type of work and/or tasks: Conducting patient interviews in order to determine eligibility of alternate funding and resources. Advise and assist individuals requesting services with a variety of problems, questions, or situations in compliance with services using alternate health care resources. Assisting patients with completing forms for alternate resources (ie. Medicare, Medicaid, Private Insurance, etc.) GS-07: Your resume must demonstrate at least one (1) year of specialized experience equivalent to at least the next lower grade level in the Federal service obtained in either the private or public sector performing the following type of work and/or tasks: Identifies and assists patients who may be eligible for coverage by third party resources. Extracts statistical data to prepare and submit reports. Reviews incoming claims for determination. Explains and interprets regulations and policies to patients and providers. Perform case by case interviews, data gathering and research to determine approval/denial of cases. GS-08: Your resume must demonstrate at least one (1) year of specialized experience equivalent to at least the next lower grade level in the Federal service obtained in either the private or public sector performing the following type of work and/or tasks: Performs prescreening process for potential eligibility and gathers pertinent information utilized to determine eligibility and potentially eligibility for alternative resources. Analyzes the facts of individual cases and researches regulations and guidelines. Conducts in-depth face-to-face interview or by telephone with patients and/or families. Maintains program files including letters of denials with all backup material for reason for denial, elective procedures, etc. Conducts regular internal review and verification of computerized financial reports. Coding procedures which requires the accurate accountability of funds. Time In Grade Federal employees in the competitive service are also subject to the Time-In-Grade Requirements: Merit Promotion (status) candidates must have completed one year of service at the next lower grade level. Time-In-Grade provisions do not apply under the Excepted Service Examining Plan (ESEP). You must meet all qualification requirements within 30 days of the closing date of the announcement. Education This position has an education requirement. You are strongly encouraged to submit a copy of your transcripts or a list of your courses including titles, credit hours completed, and grades. Unofficial transcripts will be accepted in the application package. Official transcripts will be required from all selectees prior to receiving an official offer. Only attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education may be credited. Applicants can verify accreditation at the following website: https://www.ed.gov/accreditation. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit https://sites.ed.gov/international/recognition-of-foreign-qualifications/. Additional Information Additional selection(s) of candidates may be possible within 240 days from the date the certificate of eligibles was issued for this announcement. 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. IHS may offer newly-appointed Federal employees credit for their directly related previous non-federal experience or active duty uniformed military service. This credited service can be used in determining the rate at which they earn annual leave. This position is covered by a Bargaining Unit. No recruitment or relocation incentives authorized. No government housing. This position has promotion potential to the GS-08 grade level. Promotion to the next grade level is at management's discretion and is based on your demonstrated ability to perform the higher level duties, the continuing need for the higher level duties, and "Regulatory/Administrative" approval. Promotion to the next higher grade level is not guaranteed and no promise of promotion is implied.