Claims Examiner

About the role

The 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.

What you will do

• This 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 authorized

Requirements

• 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 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 (***).
• 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.

Education

There is no educational substitution at this grade level. 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: ***

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: ***

How you will be evaluated

Your qualifications will be evaluated based on your application materials (e.g., resume, supporting documents), your responses on the application questionnaire, and your responses to all assessments required for this position.

You will be assessed on the following Competencies for this position: Attention to Detail Customer Service Decision Making Flexibility Integrity/Honesty Interpersonal Skills Learning Reading Comprehension Self-Management Stress Tolerance Teamwork Your experience must be fully documented on your resume and must include job title, duties, month and year start/end dates AND hours worked per week.

A full year of work is considered to be 35-40 hours of work per week. Part-time experience will be credited on the basis of time actually spent in appropriate activities. Applicants wishing to receive credit for such experience must indicate clearly the nature of their duties and responsibilities in each position and the number of hours a week spent in such employment.

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC.

WE WILL NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE.

Overstating your qualifications and/or experience in your application materials or application questionnaire may result in your removal from consideration. Cheating on the online assessment may also result in your removal from consideration.

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; religions; spiritual; community; student; social).

Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions.

Special Employment Consideration: VA encourages persons with disabilities to apply, including those eligible for hiring under 5 CFR 213.3102(u), Schedule A, Appointment of persons with disabilities [i.e., intellectual disabilities, severe physical disabilities, or psychiatric disabilities], and/or Disabled veterans with a compensable service-connected disability of 30% or more.

Contact the Agency Contact for information on how to apply under this appointment authority via the Selective Placement Coordinator.

Documents you must provide

• Resume SF-50/ Notification of Personnel Action The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position.
• Please make sure you have included other documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), documentation to support Veterans Preference claims, or ICTAP/CTAP documentation (for displaced Federal employees).
• You will not be contacted for additional information.
• Cover Letter Performance Appraisal Resume Separation Notice (RIF) SF-50/ Notification of Personnel Action SF-50, Notification of Personnel Action (if applicable for Time in Grade and/or Eligibility): Most recent SF-50 if you are a current or former Federal employee An SF-50 showing 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 Award 50's do not provide sufficient information and will not be accepted for the purpose of verifying time-in-grade.
• Examples of appropriate SF-50's include: Within grade increases at the highest grade held; or Promotions with an effective date more than one year old; or SF-50's at the highest grade held with an effective date more than one year old.
• Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.
• It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.
• NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons.
• Wearing a face mask is required when an exemption to the influenza vaccination has been granted.
• HCP in violation of this directive may face disciplinary action up to and including removal from federal service.
• HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties.
• VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities.
• HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities.
• HPTs may be paid or unpaid and include residents, interns, fellows and students.
• HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.
• Placement Policy: The posting of this announcement does not obligate management to fill a vacancy or vacancies by promotion.
• The position may be filled by reassignment, change to lower grade, transfer, appointment, or reinstatement.
• Management may use any one or any combination of these methods to fill the position.

What to expect next

Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required assessments and documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met.

After the review is complete, a referral certificate(s) is issued, and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.

If you are referred for consideration, you may be asked to submit additional job related information, which may include, but not limited to; responses to the knowledge, skills and abilities; completion of a work sample, and/or contact for an interview. Your resume and/or supporting documentation will be verified.

If initial application submission is updated and resubmitted with a new resume, only the most current resume will be reviewed for consideration. Please follow all instructions carefully. Errors or omissions may affect your rating or consideration for employment.

The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position.

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 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 ***