Summary The Claims Management Program Analyst Lead supervises IHSC's Claims Management Program, overseeing medical claims, provider recruitment, and compliance. Responsibilities include policy development, program evaluation, stakeholder collaboration, and contract oversight. Requires healthcare management experience and COR certification. 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. Responsibilities DUTIES AND RESPONSIBILITIES: Serves in the capacity of Claims Management Program Analyst Lead and subject matter expert (SME) in the oversight of program activities and policies related to medical claims and IHSC provider recruitment. Assumes leadership role as Acting Claims Management Program Administrator when necessary Duties include day to day managing, assessing, planning, developing, budgeting, implementing, and evaluating assigned programs. Incumbent reviews, revises, and, or writes policies, provides technical oversight on contracts, formulates, and executes short- and long- range plans for optimum utilization of personnel, facilities and equipment. 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, chairs meetings, 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). Supervises and, or, provides government technical monitor (GTM) oversight of professional staff (program analyst, provider relations liaisons, CM Program referral coordinator(s) and clerical employees in the conduct of all aspects of management of assigned functions related to administrative and personnel management. Reviews and approves leave, training, and travel requests for government staff and collaborates with vendor as GTM for contractors. Ensures adequate staffing coverage (e.g., TDY and leave absences) to meet mission and workload. Provides oversight and consultation regarding Medical Payment Authorization Requests (MedPAR)/referral for reimbursable health care services and medical claims review. Collaborates with the VAFSC and community providers to reconcile and resolve denied claims and/or appeals. Assist VAFSC, in coordinating and obtaining information pertaining to MedPARs/referrals related to eligibility. Provides oversight and consultation for recruitment and enrollment of providers into the IHSC provider network. Liaises regionally and, or, nationally with applicable stakeholders internal and external stakeholders [e.g., Customs and Border Patrol, Office of Field Operations, Homeland Security Investigation (HSI) and third party claims vendor] regarding medical claims processes, trainings, and principles. This requires contact via virtual conferences and/or telephone dialogue on a routine basis. Provides orientation and guidance to the respective ICE, custody, and medical staff members of facilities in which ICE noncitizens are held regarding CMP processes with related ICE policies. Serves as Claims Management Program lead for IHSC's third party claims vendor $100M+ Service Level Agreement (SLA). Liaises as the SME with IHSC staff and/resolution, provider reimbursement, and provider recruitment/enrollment. Coordinates and collaborates with internal and external stakeholders, including community providers, CBP stations/sectors, HSI, non-IHSC facilities and IHSC facilities to manage and adjudicate medical claims to meet the ICE/IHSC mission. 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. As a Government Technical Monitor (GTM), the incumbent works directly with the Contracting Officer Representatives (CORs) with respect to contract staff performance, time, and compliance as needed. 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 detainees 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 five 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 management, administration, or evaluation of public health programs. Healthcare management, finance or medical claims is preferred. 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 current status. The agency may require the incumbent performs clinical activities with the scope of clinical license in times of critical needs within the agency. Incumbent must possess at minimum, a Level II COR 40-hour course certificate or must obtain after one year of hire through the Defense Acquisition University (DAU) and Federal Acquisition (FAI) Cornerstone OnDemand (CSOD) online comprehensive learning platform. Project Management and/or Program Management experience preferred. Well-developed knowledge and skills in the areas of claims management and medical necessity. Supervisory experience preferred. Preferably a minimum of one year in an office now part of IHSC 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 MS Office applications and Adobe. 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 Administrator (CMPA). This is a supervisory position. HPMU focuses on medical claims program through the governance of a provider network, claims adjudication and utilization management. HPMU collaborates with the Veterans Affairs Financial Services Center (VAFSC), a third-party medical claims administrator, and offsite providers to establish letters of understanding with IHSC. HPMU also works jointly with IHSC stakeholders: pharmacy; dental; the Behavioral Health Unit; the Medical Case Management Unit; and IHSC headquarters to meet mission initiatives. HPMU trains field medical coordinators, managed care coordinators and referral coordinators to improve processes related to the recruitment and retention of outside providers and claims process workflows to decrease claims denials and increase the number of paid claims. In Fiscal Year (FY) 2024, IHSC provided direct care to more than 138,000 noncitizens 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 detained noncitizens housed in 129 non-IHSC-staffed facilities, totaling almost 45,500 beds. SUPERVISORY CONTROLS: The CM Program Analyst Lead works under the supervision of the IHSC HPMU Claims Management Program Administrator. The incumbent plans and organizes his/her own work, determines the sequence of assignments, selects and develops methods, and seeks assistance from experts only rarely. Assignments are usually long-term, recurring, or broadly defined. Work is reviewed for feasibility, compatibility with other work, and effectiveness in meeting requirements or expected results.
