Legal Administrative Specialist (Insurance Benefits Claims Examiner)

$74,642 - $97,034/Yr

United States Government - Fairfield, CA

Part-time,Full-time - Entry Level

Onsite - Fairfield, CA

Executive, Legislative, and Other General Government Support

About the position

The Legal Administrative Specialist (Insurance Benefits Claims Examiner) plays a crucial role in the Healthcare and Insurance sector of the Office of Personnel Management. This position involves reviewing health insurance disputes between enrollees and participating FEHB carriers to ensure that Federal enrollees receive the benefits negotiated by OPM. The specialist will also respond to inquiries regarding FEHB Program disputed claim regulations, health insurance coverage, and Federal enrollment eligibility.

Responsibilities

• Respond to Federal Employees Health Benefits (FEHB) inquiries from Federal enrollees and their authorized representatives.
• Prepare written directives for the Contracting Officer's signature requiring carriers to provide benefits as appropriate.
• Conduct thorough case analysis on disputed health benefits claims.
• Develop written appeal responses based on analysis and FEHB Program benefit policies and guidelines.
• Track trends and systemic claim processing errors from the disputed claim appeal process to provide recommendations for corrective action.

Requirements

• Must be a U.S. Citizen or National.
• Males born after 12-31-59 must be registered for Selective Service.
• One year of specialized experience equivalent to the GS-07 grade level, including reviewing disputed health benefits claims and appeals, responding to inquiries, and researching contracts and regulations.
• A master's or equivalent graduate degree in Healthcare Administration, Health Policy, Business Administration, Management, or related field may substitute for experience.

Nice-to-haves

• Experience in the insurance industry.
• Knowledge of health insurance regulations and policies.

Benefits

• Comprehensive benefits package as a federal employee.
• Access to a range of benefits designed to make federal careers rewarding.