Health Insurance Specialist

Summary This position is located in the Department of Health & Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), Center for Program Integrity (CPI), Provider Enrollment & Oversight Group (PEOG). As a Health Insurance Specialist, GS-0107-9/11, you will serve as the focal point for all Medicare provider and supplier enrollment compliance functions, including identifying and reporting provider enrollment related vulnerabilities that may indicate fraud, waste, or abuse. Learn more about this agency Duties Reviews financial payment data and provider enrollment records to spot potential fraud, waste, and abuse (FWA). Uses established guidelines and analytical tools to evaluate issues, conduct studies, and identify program vulnerabilities. Assists with developing, reviewing, and updating program integrity policies and regulations. Identifies policy problems, recommends solutions, and contributes to decisions that may result in new or improved rules, criteria, or agency policies particularly around administrative sanctions and integrity initiatives. Coordinates with Internal and external agencies on fraud, waste, and abuse (FWA) matters by compiling case documentation and factual summaries as well as engaging with senior officials across the healthcare industry, nonprofits, and contractors. Prepares and delivers briefing materials, summary reports, and analytical findings for senior officials and provides technical advice to internal and external stakeholders on provider enrollment, program vulnerabilities, and integrity issues. Requirements Conditions of employment You must be a U.S. Citizen or National to apply for this position. You will be subject to a background and suitability investigation. Selective Service: Male born after December 31, 1959, must be registered or exempt from Selective Service - http://www.sss.gov If you are selected for this position, the documentation that you present for purposes of completing the Department of Homeland Security (DHS) Form 1-9 will be verified through the DHS "E-Verify" System All Federal employees are required to have Federal salary payments made by direct deposit to financial institution of their choice. Qualifications ALL QUALIFICATION REQUIREMENTS MUST BE MET BY THE CLOSING DATE OF THIS ANNOUNCEMENT. Your resume (limited to no more than 2 pages) must include detailed information as it relates to the responsibilities and specialized experience for this position. Evidence of copying and pasting directly from the vacancy announcement without clearly documenting supplemental information to describe your experience will result in an ineligible rating. This will prevent you from receiving further consideration. In order to qualify for the GS-09, you must meet the following: You must demonstrate in your resume at least one year (52 weeks) of qualifying specialized experience equivalent to the GS-07 grade level in the Federal government, obtained in either the private or public sector, to include: Gathering and compiling financial program payment data, provider enrollment records, or related documentation to support investigations or inquiries involving fraud, waste, or abuse (FWA) in a health insurance program (e.g., Medicare, Medicaid, or Marketplace); AND Supporting investigations, audits, or compliance activities related to health insurance programs through collaboration with internal teams, external agencies, contractors, or oversight bodies; AND Analyzing federal health care statutes, regulations, and program integrity guidance to identify compliance concerns, program integrity issues, or policy matters related to provider enrollment or health insurance program operations, and preparing findings for reporting purposes. - OR - Substitution of Education for Experience: You may substitute education for specialized experience at the GS-09 level by possessing a Master's or equivalent graduate degree or 2 full years of progressively higher level graduate education leading to such a degree or LL.B. or J.D., if related to the position being filled. - OR - Combination of Experience and Education: Only graduate education in excess of the amount required for the GS-07 grade level may be used to qualify applicants for positions at the grade GS-09. Therefore, only education in excess of 1 full year of graduate level education may be used to combine education and experience. TRANSCRIPTS are required to verify satisfactory completion of the educational requirement related to the substitution of education for experience and the combination of experience and education. Please refer to the "Required Documents" section below for the documentation required at the time of application. In order to qualify for the GS-11, you must meet the following: You must demonstrate in your resume at least one year (52 weeks) of qualifying specialized experience equivalent to the GS-09 grade level in the Federal government, obtained in either the private or public sector, to include: Reviewing financial program payment data and provider enrollment records to identify potential indicators of fraud, waste, or abuse (FWA) in a health insurance program (e.g., Medicare, Medicaid, or Marketplace) and applying established analytical methods, protocols, and frameworks to assess FWA issues at the operational level; AND Coordinating with internal teams, external agencies, contractors, and oversight bodies to support investigations, audits, or compliance and oversight activities related to health insurance programs, including preparing factual summaries and case documentation in support of multi-agency efforts; AND Researching and applying federal health care statutes, regulations, or program integrity guidance to analyze and report on compliance concerns or program integrity issues related to provider enrollment or health insurance program operations. - OR - Substitution of Education for Experience: You may substitute education for specialized experience at the GS-11 level by possessing a Ph.D. or equivalent doctoral degree or 3 full years of progressively higher level graduate education leading to such a degree or equivalent doctoral degree or LL.M., if related to the position being filled. - OR - Combination of Experience and Education: Only graduate education in excess of the amount required for the GS-09 grade level may be used to qualify applicants for positions at the grade GS-11. Therefore, only education in excess of a master's degree or its equivalent, or 2 full years of progressively higher-level graduate education leading to such a degree, may be used to combine education and experience. TRANSCRIPTS are required to verify satisfactory completion of the educational requirement related to the substitution of education for experience and the combination of experience and education. Please refer to the "Required Documents" section below for the documentation required at the time of application. 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, 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. Click the following link to view the occupational questionnaire: https://apply.usastaffing.gov/ViewQuestionnaire/12969735 Additional information Bargaining Unit Position: Yes- American Federation of Government Employees, Local 1923 Tour of Duty: Flexible Recruitment Incentive: Not Authorized Relocation Incentive: Not Authorized Financial Disclosure: Not Required For more information on locality and pay scales, please click here. https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/2026/general-schedule/ OPM GS Pay Table: Boston, MA: GS-09: $69,905 - $90,882 GS-11: $84,579 - $109,959 Dallas, TX: GS-09: $67,100 - $87,235 GS-11: $81,186 - 105,547 Denver, CO: GS-09: $68,819 - $89,470 GS-11: $83,265 - $108,251 Seattle, WA: GS-09: $69,373 - $90,190 GS-11: $83,935 - $109,122 Woodlawn, MD: GS-09: $70,623 - $91,815 GS-11: $85,447 - $111,087 Workplace Flexibility at CMS: This position has a regular and recurring reporting requirement to the CMS office listed in this announcement. CMS offers flexible working arrangements and allows employees the opportunity to participate in alternative work schedules at the manager's discretion. The Interagency Career Transition Assistance Plan (ICTAP) and Career Transition Assistance Plan (CTAP) provide eligible displaced federal employees with selection priority over other candidates for competitive service vacancies. To be qualified you must submit the required documentation and be rated well-qualified for this vacancy. Click here for a detailed description of the required supporting documents. A well-qualified applicant is one whose knowledge, skills and abilities clearly exceed the minimum qualification requirements of the position. Additional information about ICTAP and CTAP eligibility is on OPM's Career Transition Resources website at www.opm.gov/rif/employee_guides/career_transition.asp. Expand Hide  additional information Candidates should be committed to improving the efficiency of the Federal government, passionate about the ideals of our American republic, and committed to upholding the rule of law and the United States Constitution. Benefits A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits. Review our benefits Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.