Health Insurance Specialist (Marketplace Appeal Reviewer)

Summary
This position is located in the Department of Health & Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), Office of Program Operations and Local Engagement (OPOLE).
As a Health Insurance Specialist (Marketplace Appeal Reviewer), GS-0107-13, you will be responsible for conducting additional review of Affordable Care Act Exchange (Marketplace) appeal decisions
This job is open to

• Career transition (CTAP, ICTAP, RPL)
  Federal employees who meet the definition of a "surplus" or "displaced" employee.
• Internal to an agency
  Current federal employees of this agency.

Clarification from the agency
Career Transition Assistance Plan Eligibles; OR Current Permanent Career and Career-Conditional Employees in Centers for Medicare and Medicaid Services (CMS).
Videos
Duties

• Review appeal decisions made by Federal Hearing Officers that originated from individuals regarding coverage eligibility under the Affordable Care Act's Exchanges.
• Conduct appeal decision reviews in accordance with CMS regulations.
• Research the laws, regulations, and precedents related to the facts and the issues of appeal decisions.
• Propose modifications to operations or policies to reflect changes or trends in the health care industry, program objectives, and the needs of appellants.
• Assist in developing and reviewing training and materials, and leading training for other appeal decision reviewers, contractors, and colleagues.

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.
• Time-in-Grade restrictions apply.

Qualifications
ALL QUALIFICATION REQUIREMENTS MUST BE MET WITHIN 30 DAYS OF THE CLOSING DATE OF THIS ANNOUNCEMENT.
Your resume 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-13 , 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-12 grade level in the Federal government, obtained in either the private or public sector, to include:
1) Analyzing and evaluating applicants' eligibility for participation in the Health Insurance Exchange (Marketplace) or Medicaid or Children's Health Insurance Program (CHIP) programs.
2) Resolving problems and complaints from customers seeking Health Insurance coverage.
3) Providing guidance, technical assistance, and recommendations to internal and external stakeholders on the operations of the Health Insurance Exchange (Marketplace) or Medicaid or CHIP..
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.
Time-in-Grade: To be eligible, current Federal employees must have served at least 52 weeks (one year) at the next lower grade level from the position/grade level(s) to which they are applying.
Click the following link to view the occupational questionnaire: https://apply.usastaffing.gov/ViewQuestionnaire/12223542
Education
This job does not have an education qualification requirement.
Additional information
Bargaining Unit Position: Yes-American Federation of Government Employees, Local 1923
Tour of Duty: Flexible
Recruitment/Relocation Incentive: Not Authorized
Financial Disclosure: Not Required
Workplace Flexibility at CMS: CMS offers flexible working arrangements and allows employees the opportunity to participate in telework combined with alternative work schedules at the manager's discretion. This position may be authorized for telework. Telework eligibility will be discussed during the interview process.
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.
For more information on locality and pay scales, please click here.

• 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.

How You Will Be Evaluated
You will be evaluated for this job based on how well you meet the qualifications above.
Once the announcement has closed, your online application, resume, and CMS required documents will be used to determine if you meet eligibility and qualification requirements listed on this announcement. If you are found to be among the top qualified candidates, you will be referred to the selecting official for employment consideration. Please follow all instructions carefully. Errors or omissions may affect your rating.
Your qualifications will be evaluated on the following competencies (knowledge, skills, abilities and other characteristics):

• Analysis
• Health Insurance
• Oral Communication
• Written Communication

• 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.
• Required Documents
  As a new or existing federal employee, you and your family may have access to a range of benefits. Your benefits depend on the type of position you have - whether you're a permanent, part-time, temporary or an intermittent employee. You may be eligible for the following benefits, however, check with your agency to make sure you're eligible under their policies.
  The following documents are REQUIRED:
  1. Resumeshowing relevant experience; cover letter optional. Your resume must indicate your citizenship and if you are registered for Selective Service if you are a male born after 12/31/59. Your resume must also list your work experience and education (if applicable) including the start and end dates (mm/yyyy) of each employment along with the number of hours worked per week. For work in the Federal service, you must include the series and grade level for the position(s). Your resume will be used to validate your responses to the assessment tool(s). For resume and application tips visit: https://www.usajobs.gov/Help/faq/application/documents/resume/what-to-include/
  2. CMS Required Documents (e.g., SF-50, DD-214, SF-15, etc.). Current CMS employees are REQUIRED to submit a copy of their most recent Notification of Personnel Action (SF-50) at the time of application. Additional documents may also be required to be considered for this vacancy announcement. Click here for a detailed description of the required documents. Failure to provide the required documentation WILL result in an ineligible rating OR non-consideration.
  PLEASE NOTE: A complete application package includes the online application, resume, and CMS required documents. Please carefully review the full job announcement to include the "Required Documents" and "How to Apply" sections. Failure to submit the online application, resume and CMS required documents, will result in you not being considered for employment.
  Additional Forms REQUIRED Prior to Appointment:
  
  • Optional Form 306, Declaration of Federal Employment and the Background/Suitability Investigation - A background and suitability investigation will be required for all selectees. Appointment will be subject to the successful completion of the investigation and favorable adjudication. Failure to successfully meet these requirements may be grounds for appropriate personnel action. In addition, if hired, a reinvestigation or supplemental investigation may be required at a later time. If selected, the Optional Form 306 will be required prior to final job offer. Click here to obtain a copy of the Optional Form 306.
  • Form I-9, Employment Verification and the Electronic Eligibility Verification Program - CMS participates in the Electronic Employment Eligibility Verification Program (E-Verify). E-Verify helps employers determine employment eligibility of new hires and the validity of their Social Security numbers. If selected, the Form I-9 will be required at the time of in-processing. Click here for more information about E-Verify and to obtain a copy of the Form I-9.
  • Standard Form 61, Appointment Affidavits - If selected, the Standard Form 61 will be required at the time of in-processing. Click here to obtain a copy of the Standard Form 61.
  
  If you are unable to apply online or need to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application.
• How to Apply
  Your complete application package, as described in the "Required Documents" section, must be received by 11:59 PM ET on 12/10/2023 to receive consideration.
  IN DESCRIBING YOUR WORK EXPERIENCE AND/OR EDUCATION, PLEASE BE CLEAR AND SPECIFIC REGARDING YOUR EXPERIENCE OR EDUCATION.
  We strongly encourage applicants to utilize the USAJOBS resume builder in the creation of resumes. Please ensure EACH work history includes ALL of the following information:
  
  • Official Position Title (include series and grade if Federal job)
  • Duties (be specific in describing your duties)
  • Employer's name and address
  • Supervisor name and phone number
  • Start and end dates including month and year (e.g. June 2007 to April 2008)
  • Full-time or part-time status (include hours worked per week)
  • Salary
  
  Determining length of general or specialized experience is dependent on the above information and failure to provide ALL of this information WILL result in a finding of ineligible.
  
  • To begin, click Apply to access the online application. You will need to be logged into your USAJOBS account to apply. If you do not have a USAJOBS account, you will need to create one before beginning the application.
  • Follow the prompts to select your resume and/or other supporting documents to be included with your application package. You will have the opportunity to upload additional documents to include in your application before it is submitted. Your uploaded documents may take several hours to clear the virus scan process.
  • After acknowledging you have reviewed your application package, complete the Include Personal Information section as you deem appropriate and click to continue with the application process.
  • You will be taken to the online application which you must complete in order to apply for the position. Complete the online application, verify the required documentation is included with your application package, and submit the application.
  
  To verify the status of your application, log into your USAJOBS account (https://my.usajobs.gov/Account/Login), all of your applications will appear on the Welcome screen. The Application Status will appear along with the date your application was last updated. For information on what each Application Status means, visit: https://www.usajobs.gov/Help/how-to/application/status/.
  This agency provides reasonable accommodation to applicants with disabilities. If you need a reasonable accommodation for any part of the application or hiring process, please send an email to hrinquiries@cms.hhs.gov. The decision to grant reasonable accommodation will be made on a case-by-case basis.
  Commissioned Corps Officers (including Commissioned Corps professionally boarded applicants) who are interested in applying for this position must send their cover letter and professional resume (not PHS Curriculum Vitae) to CMSCorpsJobs@cms.hhs.gov in lieu of applying through this announcement. The resume should specifically explain how you are qualified for this position and draw specific attention to your skills and experiences that demonstrates these qualifications. Also send any transcripts, licenses or certifications as requested in this announcement. Please send all documents in 1 PDF file. In the subject line of your e-mail include only the Job Announcement Number. In the body of your e-m...