Summary Serves as a Legal Administrative Specialist (Contact Representative) supporting an eligibility and benefits notification process, ensuring proper notification of rights to claimants. Provides administration of benefits provisions for a variety of programs (e.g., Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), Foreign Medical Program (FMP) Camp Lejeune Family Member Program (CLFMP.) Assist claimants in obtaining evidence to substantiate their request. Responsibilities Duties include but are not limited to: Determines documentation necessary to substantiate benefit coverage under each of the specific program laws, regulations, and/or operational policies. Reviews claims for duplicate detection, missing or discrepant data, and medical audits. Determines whether criteria for eligibility have been met by or inappropriately awarded to claimants. Reviews operational policy manuals, pertinent laws, Agency regulations and precedents, and claims processing methodology and business rules to determine reason(s) for denial. Drafts formal summaries of evidence and guidelines related to benefits denial notifications for routing to claimants; identifies pertinent requirements within the law that were not satisfied. Provides instructions on how to submit requests for higher-level review, or the option to present appeals before the Board of Veterans' Appeals program. Uses system reports, the claims processing and eligibility system (i.e., CP&E), Claims XM, U.S. Code, Code of Federal Regulations, operations policy manuals, benefit applications, and medical claims evidence to determine appropriate decision notifications. Contacts claimants medical providers, educational institutions, commercial insurance companies, and a wide variety of government organizations to assist claimants. Provides input and assessments on recommended changes and requirements related to appeals modernization to facilitate changes to automated processes. Participates in extensive interaction with the supervisor, personnel in other directorates within IVC VFMP and may include commercial and private sector entities. Promotion Potential: The selectee may be promoted to the full performance level without further competition when all regulatory, qualification, and performance requirements are met. Selection at a lower grade level does not guarantee promotion to the full performance level. Work Schedule: Monday- Friday 6:00 a.m.- 4:30 p.m. EST Telework: This position may be authorized for Ad-Hoc telework. Telework eligibility will be discussed during the interview process. Virtual: This is not a virtual position. Position Description/PD#: Legal Administrative Specialist (Contact Representative)/PD36794A and PD15070A Relocation/Recruitment Incentives: Not Authorized Critical Skills Incentive (CSI): Not Authorized Permanent Change of Station (PCS): Not Authorized Requirements Conditions of Employment You must be a U.S. Citizen to apply for this job To be considered for this position, you must complete all required steps in the process. In addition to the application and questionnaire, this position requires an online assessment. The online assessment measures critical general competencies required to perform the job. Selective Service Registration is required for males born after 12/31/1959 Physical Requirements: The work required does not inherently include any physical requirements essential for successful job performance that could not otherwise be performed with accommodation or workplace adjustment. A pre-placement physical examination is not required. Subject to background/security investigation Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP) As a condition of employment for accepting this position, you will be required to serve a 1-year probationary period or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service. Upon completion of your probationary period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest. Qualifications To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 06/08/2026. Time-In-Grade Requirement: Applicants who are current Federal employees and have held a GS grade any time in the past 52 weeks must also meet time-in-grade requirements by the closing date of this announcement. For a GS-07 position you must have served 52 weeks at the GS-05. For a GS-09 position you have served 52 weeks at the GS-07. The grade may have been in any occupation, but must have been held in the Federal service. An SF-50 that shows your time-in-grade eligibility must be submitted with your application materials. If the most recent SF-50 has an effective date within the past year, it may not clearly demonstrate you possess one-year time-in-grade, as required by the announcement. In this instance, you must provide an additional SF-50 that clearly demonstrates one-year time-in-grade. Note: Time-In-Grade requirements also apply to former Federal employees applying for reinstatement as well as current employees applying for Veterans Employment Opportunities Act of 1998 (VEOA) appointment. You may qualify based on your experience and/or education as described below: Specialized Experience GS-07: You must have one year of specialized experience equivalent to at least the next lower grade GS-05 in the normal line of progression for the occupation in the organization. Examples of specialized experience would typically include, but are not limited to: Applied United States Code and Federal Regulations to assist in determining eligibility for Veteran Family Member Programs Assisted claimants in obtaining evidence to substantiate their medical claim submission request. Demonstrated experience utilizing health care industry operations; including claims processing procedures and medical reimbursement techniques. Demonstrated basic experience utilizing medical coding systems (e.g. ICD-9/10, HCPCS, CPT, ADA, DSM) Reviewed and verified health care program documentation and benefits to support eligibility assessments and escalate complex cases to senior staff when required OR, Education: Applicants may substitute education for the required experience. To qualify based on education for this grade level you must have 1 full year of graduate level education or superior academic achievement (see Education section below for additional information). OR, Combination: Applicants may also combine education and experience to qualify at this level. You must have an combination of specialized experience and education beyond undergraduate level. Specialized Experience GS-09: You must have one year of specialized experience equivalent to at least the next lower grade GS-07 in the normal line of progression for the occupation in the organization. Examples of specialized experience would typically include, but are not limited to: Interpreted and applied United States Code and Federal Regulations to determine eligibility for Veteran Family Member Programs and to ensure claims were processed in alignment with established policies. Contacted medical providers and other health insurance agencies to assist claimants in the collection of necessary documentation for eligibility or medical claim consideration. Determined what information is necessary to adjudicate claims. Demonstrated experience utilizing health care industry operations; including claims processing procedures and medical reimbursement techniques to resolve claimant or provider issues. Demonstrated experience utilizing medical coding systems (e.g. ICD-9/10, HCPCS, CPT, ADA, DSM) to route claims accurately, validate documentation, and ensure correct processing in accordance with program policies and coding regulations. Applied analytical skills. Reviewed claims for duplicate detection, missing or discrepant data OR, Education: Applicants may substitute education for the required experience. To qualify based on education for this grade level you must have a Master's or equivalent graduate degree OR, 2 full years of progressively higher level graduate education leading to such a degree OR, LL.B. or J.D., if related OR, Combination: Applicants may also combine education and experience to qualify at this level. You must have an combination of specialized experience and education beyond undergraduate level. For more information on these qualification standards, please visit the United States Office of Personnel Management's website at https://www.opm.gov/policy-data-oversight/classification-qualifications/general-schedule-qualification-standards/. Education A transcript must be submitted with your application if you are basing all or part of your qualifications on education. Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.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/. Superior Academic Achievement: (SAA) recognizes students who have achieved superior academic standing as evidenced by one of the three methods described below. In order to be creditable under this provision, superior academic achievement must have been gained in a curriculum that is qualifying for the position to be filled. Applicants who wish to apply under this provision must submit proof from their educational institution that they meet one of the criteria listed below. To qualify for SAA, applicants must have completed all the requirements for a bachelor's degree in a curriculum that is qualifying for the position to be filled and meet one of the following: 1. Rank in the upper one-third of your class in the college, university, or major subdivision. 2. A grade-point average of at least "B" (a GPA of 3.0 or higher out of a possible 4.0) for all completed undergraduate courses, or those completed in the last two years of undergraduate study. 3. A grade point average of at least "B+" (a GPA of 3.5 or higher out of a possible 4.0) average of required courses completed in the major field of study or required courses in your major completed in the last two years of undergraduate study. 4. Membership in a national honor society. Membership in a freshman honor society cannot be used. Honor societies recognized by Association of College Honor Societies. For a list of recognized honor societies please visit https://www.achshonor.org/. For more information regarding SAA please visit https://www.opm.gov/policy-data-oversight/classification-qualifications/general-schedule-qualification-policies/#url=General-Policies. Additional Information Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act. Reasonable Accommodation (RA) Requests: If you believe you have a disability (i.e., physical or mental), covered by the Rehabilitation Act of 1973 as amended that would interfere with completing the USA Hire Competency Based Assessments, you will be granted the opportunity to request a RA in your online application. Requests for RA for the USA Hire Competency Based Assessments and appropriate supporting documentation for RA must be received prior to starting the USA Hire Competency Based Assessments. Decisions on requests for RA are made on a case-by-case basis. If you meet the minimum qualifications of the position, after notification of the adjudication of your request, you will receive an email invitation to complete the USA Hire Competency Based Assessments, based on your adjudication decision. You must complete all assessments within 48 hours of receiving the URL to access the USA Hire Competency Based Assessments if you received the link after the close of the announcement. To determine if you need a RA, please review the Procedures for Requesting a Reasonable Accommodation for Online Assessments. This job opportunity announcement may be used to fill additional vacancies. The Interagency Career Transition Assistance Plan (ICTAP) and Career Transition Assistance Plan (CTAP) provide eligible displaced VA competitive service employees with selection priority over other candidates for competitive service vacancies. To be qualified you must submit appropriate documentation (a copy of the agency notice, your most recent performance rating, and your most recent SF-50 noting current position, grade level, and duty location) and be found well-qualified for this vacancy. To be well-qualified: applicants must possess experience that exceeds the minimum qualifications of the position including all selective factors, and who are proficient in most of the required competencies of the job. Information about ICTAP and CTAP eligibility is on OPM's Career Transition Resources website at http://www.opm.gov/policy-data-oversight/workforce-restructuring/employee-guide-to-career-transition/.
