Summary The work is applying expert knowledge of Purchased/Referral Care regulations to identify and assist patients who may be eligible for coverage by third party resources for patient care and to ensure the medical care provided by third party resources is paid. This job announcement is to fill a number of positions between December 2024 and March 2025. We are accepting applications with eligible applicants being placed on a standing register and referred for consideration as vacancies occur. Responsibilities Please Take Note: Individuals working at the Wellpinit Service Unit will be under tribal management in March 2025. Public Law 93-638 gave Tribes the authority to contract for the direct operation of Indian Health Service programs serving their tribal members. If you are hired through this job announcement, you will be subject to future employment under the Spokane Tribe of Indians. The tribe can exercise options to utilize Federal personnel on Intergovernmental Personnel Act (IPA) assignments and Memoranda of Agreements (MOA) but future employment is not guaranteed. MAJOR DUTIES: If selected candidate is hired at the grade level GS-06, the selected candidate gains experience toward the next level of grade level GS-07 and until the full performance level of GS-08 is achieved. The major duties are listed below. Conducts in-depth face-to-face interview or by telephone with patients and/or families to ensure accurate completion of enrollment application. Assist the applicant to ensure State Medicaid enrollment application is thoroughly complete. Advises the patient/family/non-IHS providers of eligibility based on information gathered at the time of a face-to-face interview or by letter form after all necessary information has been reviewed. Performs prescreening process for potential eligibility and gathers pertinent information utilized to determine eligibility and potentially eligibility for alternative resources. Verifies and determines patient's eligibility for Medicare, Medicaid, Private Insurance, Veteran Administration or other potential alternate resources as appropriate, which are available and accessible to the individual. Determines the sufficiency of the documentation submitted for consideration. Initiates action with appropriate office(s) in order to obtain the required documentation or information (i.e. supporting documents and evidence). Prepares memoranda for correspondence for the reviewing appeals, identifies deficiencies and recommends appropriate course of action. Performs substantive research in the areas of medical documentation, administrative compliance, inquiries and reports of investigation and standards of conduct/ethics. Ensures that Purchased/Referred Care funds are available prior to issuance of obligating documents on behalf of the government. Provides forecasting of weekly document control register balances after each week's obligations have been completed to ensure funds are expended in accordance within the spending plans. Initiates medical authorizations and denial of service for inpatient/outpatient/ancillary medical services for eligible IHS beneficiaries. Reviews completed documents for accurate patient information, clinical data, obligation signatures and fiscal data. In appeals or denials, employee gathers all necessary information pertinent to the case for the episode of care and completes final review and determination of a reversal and/or affirmed denial. There may be times when the staff will have to write out the draft appeal letter for the patient; especially those for non-English speaking individuals. Requirements Conditions of Employment Selectee may be subject to a probationary/trial period ESEP appointees typically serve a two year trial period U.S. Citizenship is required Selective Service Registration is required for males born after 12/31/1959 This is a designated position covered by Public Law 101-630, requiring contact or control over Indian children. Due to this requirement, the agency must ensure that persons hired for these positions have not been found guilty of or pleaded nolo contendere or guilty to certain crimes. Adherence to the IHS Employee Immunization Policy, SGM 21-04, and the IHS Circular 2016-04 requiring Measles and Rubella, COVID-19, and seasonal influenza immunizations for staff working in Indian Health Service health care facilities OR an exemption request will need to be submitted. Successfully pass the E-Verify employment verification check. To learn more about E-Verify, including your rights and responsibilities, visit www.dhs.gov/E-Verify/. You will need to set up direct deposit so we can pay you. Background Investigation: If you are selected for this vacancy, you must undergo a pre-employment fingerprint check and background investigation. Fingerprint results and background investigation documentation must be cleared prior to hire. After you begin your employment, your continued employment is contingent upon the outcome of a complete background investigation as determined by the sensitivity level of your position. The investigation must find that you are suitable for Federal employment in your position. If you are found not suitable, you will be terminated after you begin work. If you make a false statement in any part of your application, you may not be hired; you may be fired after you begin work; or subject to possible criminal charges. You may be subject to a credit check as a part of the background investigation process. Qualifications To qualify for this position, your resume must state sufficient experience and/or education, to perform the duties of the specific position for which you are applying. Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religious; spiritual; community; social). You will receive credit for all qualifying experience, including volunteer and part time experience. You must clearly identify the duties and responsibilities in each position held and the total number of hours per week. The following minimum qualifications shows the amounts of education and/or experience required to qualify for Contact Representative positions taken from the appropriate qualification standard. MINIMUM QUALIFICATIONS For Grade GS-06 Your resume must demonstrate at least one (1) year of specialized experience equivalent to at least the next lower grade level in the Federal service obtained in either the private or public sector performing the certain type of work and/or tasks. Examples include provide clerical duties such as making appointments, data entry, maintaining files, and answering phone calls; Conduct interviews in order to determine patient's eligibility for Purchased/Referred Care services; Issue medical referrals and denial letters for medical services; Communicate with patients regarding medical bills, claim status, and referrals. MINIMUM QUALIFICATIONS For Grade GS-07 Your resume must demonstrate at least one (1) year of specialized experience equivalent to at least the next lower grade level in the Federal service obtained in either the private or public sector performing the certain type of work and/or tasks. Examples include assess and educate patients in regard to unique health services and program eligibility; Initiate medical authorizations and denial of service for medical services; Prepare and distribute purchase order authorizations for patient care services and ensure prompt payment; Research vendor claims and purchase orders to provide prompt follow-up; Review incoming claims from providers to determine if authorizations are approved or denied. MINIMUM QUALIFICATIONS For Grade GS-08 Your resume must demonstrate at least one (1) year of specialized experience equivalent to at least the next lower grade level in the Federal service obtained in either the private or public sector performing certain types of work and/or tasks. Examples include: Prepare and distribute purchase order authorizations for patient care services and ensure prompt payment; Conduct comprehensive patient interviews to determine eligibility for alternate health insurance resources; Provide recommendations to patients on the various health care benefit programs and eligibility criteria based on current health care laws and regulation; Conduct extensive research and providing benefit updates involving changes in rules and regulations for alternate resources; Review financial reports for reconciliation with outstanding accounts and progressive payments to ensure accuracy. Specialized Experience Experience that equipped the applicant with the particular knowledge, skills, and abilities (KSA's) to perform successfully the duties of the position, and that is typically in or related to the position to be filled. To be creditable, specialized experience must have been equivalent to at least the next lower grade level. Note: Creditable experience is experience of the type (general or specialized), level, and amount specified in the appropriate standard. Applicants are considered to have satisfied the requirement for 1 year of experience through completion of either 12 months or 52 weeks of creditable work experience, whichever comes first. Time In Grade Federal employees in the competitive service are also subject to the Time-In-Grade Requirements: Merit Promotion (status) candidates must have completed one year of service at the next lower grade level. Time-In-Grade provisions do not apply under the Excepted Service Examining Plan (ESEP). You must meet all qualification requirements within 30 days of a cut-off date or the closing date of the announcement. Cut-off date(s) are established based on the date the human resources office receives management request for a list of eligibles or every 10 days thereafter. The job announcement is open continuous until the closing date. Education As a general rule, education is not creditable above the grade GS-5 for most positions covered by this standard; however, graduate education may be credited in those few instances where the graduate education is directly related to the work of the position. Additional Information This position is eligible for workplace flexibilities which may include remote work or telework options, and/or flexible work scheduling. These flexibilities may be requested in accordance with the HHS Workplace Flexibilities policy. https://www.hhs.gov/about/agencies/asa/ohr/hr-library/990-1/index.html. Additional selection(s) of candidates may be possible within 240 days from the date the certificate of eligibles was issued for this announcement. Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. IHS may offer newly-appointed Federal employees credit for their directly related previous non-federal experience or active duty uniformed military service. This credited service can be used in determining the rate at which they earn annual leave. Recruitment or relocation incentives may be authorized. At least a 6 month service agreement will be required. This position has promotion potential to the GS-08 grade level. Promotion to the next grade level is at management's discretion and is based on your demonstrated ability to perform the higher level duties, the continuing need for the higher level duties, and "Regulatory/Administrative" approval. Promotion to the next higher grade level is not guaranteed and no promise of promotion is implied.