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Summary 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 Responsibilities 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. Requirements Conditions of Employment 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 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). Education REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES: Incumbent must possess a minimum of three 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 program management, administration, Healthcare management, finance or medical claims is preferred. Qualifying degree for the officer's category from an accredited institution 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. If in a clinical discipline and as directed and approved by his/her supervisors, the incumbent may perform clinical duties of their profession in Federal health care facilities. Such direction is documented via a memorandum of assignment and is filed in the eOPF. Well-developed knowledge and skills in the areas of claims management and medical necessity. 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 MicroSoft Office applications, and Sharepoint applications. Additional 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), Office of Deputy Assistant Director for Healthcare Compliance, Office of Health Plan Management Unit (HPMU). The incumbent reports directly to the IHSC Claims Management Program Analyst Lead (CMP). This is a non-supervisory position. HPMU's focus is on the claims management program through the governance of a provider network, claims adjudication, referral management and utilization management. HPMU collaborates with a third-party administrator, and off-site community providers to establish letters of understanding with IHSC. HPMU also works jointly with IHSC stakeholders: pharmacy; dental; Behavioral Health Unit; Field Medical Coordination Unit; and IHSC headquarters to meet mission initiatives. HPMU trains field medical coordinators, and referral coordinators to improve processes related to the recruitment and retention of off-site community providers and claims process workflows to decrease claims denials and increase the number of paid claims IHSC has a multi-sector, multidisciplinary workforce of more than 1400 employees, including U.S. Public Health Service (PHS) commissioned officers, federal civil servants, and contract staff. In Fiscal Year (FY) 2024, IHSC provided direct care to more than 138,000 illegal aliens housed in 18 facilities throughout the nation to include medical, dental, and mental health care, and public health services. In FY 2024, IHSC oversaw compliance with health-related standards for over 186,900 illegal aliens housed in 129 non-IHSC-staffed facilities, totaling almost 45,500 beds SUPERVISORY CONTROLS: The Claims Management Program Analyst works under the supervision of the IHSC Claims Management Program Analyst Lead. Assignments are usually of a long-term, recurring, or broadly defined nature. Officer plans, and organizes own work, determines sequence of assignments, selects, and develops methods and seeks assistance from experts only rarely. Work is reviewed feasibility, compatibility with other work, and effectiveness in meeting requirements or expected results and objectives. Guidelines may be applicable to some but not all parts of assignment and may contain some inconsistencies and be partially unconfirmed. Selection and adaption from available possibilities involving a moderate amount of modifications and innovation is required. The officer uses judgement in interpreting and adapting guidelines such as policies, regulations, training precedents and work direction for application to specific cases. The officer analyses results and recommends changes in guidelines and program policies. Innovations and modifications to accepted procedures must be approved and clearly documented. The officer keeps the supervisor informed of the status on projects and consults with him/her on any significant problems encountered.