Claims Management Program Analyst (O-5 Billet) Non-Supervisory

DUTIES AND RESPONSIBILITIES: Serves in the capacity of claims Management Program Analyst and subject matter expert (SME) in the oversight of program activities and policies related to medical claims and IHSC provider recruitment.

Serves as one of the primary points of contact and liaison to the claims processing third-party administrator (TPA) on issues related to medical claims processing, denials, appeals provider reimbursement, provider recruitment, and resolutions. Assumes leadership role as Acting Claims Management Program lead when necessary.

Duties include day-to-day managing, assessing, planning, developing, budgeting, implementing, and evaluating assigned programs.

Incumbent ensures compliance with program regulations (e.g., appropriateness of health care and services based on regulatory, reimbursement requirements, 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).

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 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 patients are held regarding CMP processes with related ICE policies.

Serves as Claims Management Program SME for IHSC's TPA claims processor. Liaises as the SME with IHSC staff and the TPA claims processor on issues relating to claims, medical claims processing/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 administratively manage and adjudicate medical claims to meet the IHSC mission.

Assists TPA and stakeholders when necessary, in coordinating and obtaining information pertaining to referrals, authorization or information pertaining to eligibility in the alien tracking system. Coordinates the purchase or rental of durable medical equipment for detainees in ICE custody.

Creates and submits various reports for CMP Administrator, IHSC leadership as well as external stakeholders. Develops specific goals and plans to prioritize, organize, and accomplish positive outcomes with chain of command for business plans and strategic plans.

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.

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 1⁄4 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).