About this role
Job SummaryThe purpose of this position is to ensure timely access to healthcare for thousands of beneficiaries domestically and more than six million eligible service-connected Veterans around the world. The position supports beneficiary and Veteran well-being through prompt claim reimbursement to thousands of domestic and international healthcare providers.
QualificationsTo qualify for this position, applicants must meet all requirements by the closing date of this announcement, 09/22/2026. 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-08 position you must 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 as described below: Specialized Experience: 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. NOTE: To be minimally qualified for this position, you must meet the following examples of specialized experience. Examples of specialized experience would typically include, but are not limited to: Evaluate medical documentation to determine benefit eligibility and appropriate payment decisions. Review and interprets healthcare information including diagnoses, procedures, treatment notes, and medical terminology. Use industry standard coding systems and software to translate medical descriptions into standardized codes for claims processing and reimbursement. Experience with health insurance policy and plan types to include commercial, federal, and state plans. Manage high volume or fast paced customer interactions with patience and empathy while maintaining accuracy, professionalism, and a strong commitment to service. 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/.
Major DutiesThis job announcement will remain open for 8 business days. The initial application review cut-off for this job announcement is 50 applications. Applications received up to 11:59pm EST on the date in which 50 applications is reached will receive first consideration (initial cutoff). Applications received after 11:59pm EST on the date in which 50 applications are received may not receive consideration unless otherwise requested by management. Additional applications will be reviewed in one-day increments at management request. Note: Submitting multiple applications will change the order in which your application is reviewed. Examine claims to consider whether the condition treated is service-connected or associated with and aggravating a service-connected condition. Review accuracy and completeness of submitted documentation; analyzes the diagnostic and procedure codes (reasons for medical care and procedures performed); considers FDA indications and unlabeled indications for medications; and completes the conversion of foreign currency to U.S. dollars in accordance with FMP 38 U.S.C. §1724. Identify and resolve other issues associated with the request for payment prior to adjudication. Develops and evaluates relevant documentation related to Veteran/beneficiary claims submitted for payment; the incumbent examines expenditures for accuracy, adequacy of documentation, citations, compliance with regulations, and justifications for Specialty Program payment. Evaluate and process provider health care claims that are being corrected or reconsidered for payment; this requires extensive research via systems including Customer Relations Manager (CRM), claim adjudication software, document management systems that contain claim attachments, and National Provider Identification (NPI) online. Handles escalated claims referenced in high-level government inquiries (Congressional, White House, Secretary of VA), reporting findings, analysis, and recommendations for corrective action in professional correspondence. Collect and store vendor data so that the foreign banking information can be used to pay foreign providers by Electronic Funds Transfer (EFT). Ensure foreign vendors are paid into foreign financial institutions where their company is located to improve payment integrity, address fraud risk concerns brought up by the GAO and SVAC, ensure regulatory compliance with the U.S. Bureau of Fiscal Service International Treasury Service (ITS) and Office of Foreign Assets control (OFAC), and provide greater assurance that U.S. government funds are transferred to legitimate foreign entities in accordance with 38 USC §1724. Independent research, case management, and customer service techniques when assisting beneficiaries, Veterans, and providers in gathering required information from internal and external sources to complete or correct their applications, vendor forms, and claims, in accordance with the Veterans Claims Assistance Act (Public Law 106-475). Providing claim forms and instructions to Veterans and providers on how to complete applications and claims; assisting with Direct Deposit Enrollment; and providing notice of incomplete applications and claims with information needed from the Veteran, beneficiary, or provider to substantiate the claim. Use National Plan and Provider Enumeration System for domestic provider research; VA systems of record for Veteran and beneficiary research; and the VBA and Financial Services Center for banking information. Other duties as assigned Work Schedule: Mon-Fri - Work schedule will be between the hours of 6:00 am - 4:30 pm Compressed/Flexible: : May be available at management's decision. Telework: This position may be authorized for ad hoc telework. Telework eligibility will be discussed during the interview process. Ad hoc is defined as occasional, non-recurring telework. Return to Office (RTO): RTO mandates are in effect and selectees will be required to report to in-person work unless they are approved for an exception or an exemption. Any approval for an RTO exception, exemption, or extension will happen after a tentative job offer, but before a final job offer. Position Description/PD#: Claims Examiner/PD22768A Relocation/Recruitment Incentives: Not authorized. Critical Skills Incentive (CSI): Not approved. Permanent Change of Station (PCS): Not authorizedRequirementsYou 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 is primarily sedentary with occasional requirements to walk around in an office building to meet with employees. Most work requirements involve using a computer and standard office automation equipment. The incumbent may need to stoop, bend, reach, or occasionally carry loads weighing up to 20 pounds. 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 identification 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.