Health Insurance Specialist
The incumbent serves as a program expert in the Program Integrity Branch of the
Western Consortium Division of Medicare Financial Management, providing
specialized technical support to Medicare contractors and other CMS
components in fraud and abuse. The incumbent serves as a program expert
performing assignments requiring a wide latitude for the exercise of independent
judgment, work of unusual difficultly and responsibility requiring extended
administrative training and experience which has demonstrated leadership and
Possesses in-depth knowledge of those Medicare laws, regulations and policies
affecting assigned areas of responsibility. Reports and disseminates significant
trends and items of interest in health care fraud from throughout the country, in
Medicare and Medicaid, to the Regional Administrator, team members and other
program components. Plans, leads and participates in conferences,
consultations and meetings for development of new or revised policy and
procedures and guide materials on various aspects of Medicare and Medicaid
fraud and abuse.
Represents management staff when they are unavailable due to travel and in
direct communications with Central Office. Represents CMS in task forces of
multi-functional and/or multi-organizational components dealing with fraud and
abuse prevention, detection and resolution and represents the Regional Office on
national work groups and technical advisory groups.
Reviews and analyzes new and/or revised Federal laws, regulations, policies and
procedural guidelines as they apply to highly complex, controversial or sensitive
issues under the Medicare program safeguard program. Advises Central Office
of possible technical flaws and impact of regulations and guidelines.
Serves as a consultant to the Assistant United States Attorneys and other
Department of Justice personnel in Medicare fraud cases. As required, serves
as an expert witness before Federal Grand Juries and in U.S. courts in cases
involving Medicare fraud or abuse. Assists OIG in sanction and civil money
penalty activities as required.
Monitors and evaluates Medicare contractor operations to ensure adherence to
the terms and provisions of the contract and the intent of the law and pertinent
regulations, including potential conflicts of interest.
Oversees and/or participates in contractor inspections and evaluation reviews
and in the preparation of CPE reports. Provides advice to contractors on
Medicare program requirements and provides assistance on implementing new
requirements and regulations. Develops and/or conducts training, consulting and
technical assistance for CMS, contractor, State agency or other staff in subject
matters related to areas of responsibility.
Analyzes and oversees operational needs and requirements in carrying out tasks
as a project/team leader. Develops operational guidelines in assigned areas,
often for which precedents do not exist. Coordinates special projects and reports
assigned by branch manager and/or central office, as appropriate.
Plans, develops and implements studies of assigned problem areas.
Prepares responses to public, congressional and other inquiries.
Develops and utilizes innovative technologies to identify trends and patterns to
facilitate earlier detection of abusive providers. Conducts program vulnerability
assessments to provide CMS with an ongoing knowledge of the effectiveness of
policies and procedures designed to protect the Medicare program from fraud
Factor 1 - Knowledge Required by the Position
Expert knowledge of analytical and evaluative methods and a thorough
understanding of regulatory or enforcement programs to determine the extent of
compliance with regulations and CMS policies and procedures, and to measure
and evaluate program accomplishments.
Broad knowledge of CMS' structure, mission, programs, and organizational
relationships. This is used for coordinating and facilitating receipt and exchange
Broad knowledge of all aspects of the Medicare program including Federal laws,
regulations, CMS policies and procedure affecting fraud and abuse prevention
Knowledge of the interrelations of other Federal, State and private insurance
programs affecting assigned area(s). This knowledge is required to give
authoritative advice, assess contractor performance, and implement program
Comprehensive knowledge of pertinent statistical, accounting, budget and
economic principles and techniques to analyze and evaluate program
Skill in gathering, evaluating, analyzing and developing factual information for
use in drawing conclusions and devising solutions to assigned problems.
Skill in planning, developing and conducting comprehensive projects or studies to
evaluate proposals, to improve operations, and to provide reliable information to
Medicare managers on proposals to change procedures.
Skill in effectively presenting clear and concise factual information both verbally
and in writing.
Skill in negotiating to gain acceptance of complex and controversial issues.
Skill in gaining cooperating and in cooperating with others for use in developing
and completing assigned duties.
Skill in conducting interviews and establishing and maintaining effective
relationships with supervisors, employees, administrative and operating officials,
and others for use in coordinating the completion of assignments.
Skill in managing the work of the team to achieve the goals of the project or
Factor 2 - Supervisory Controls
Works under the broad supervision of the branch chief. The incumbent
independently plans and carries out monitoring and evaluation functions,
selecting the approaches and methods to be used in assessing performance.
Some approaches are established whiles others are innovative, unusual or
discretionary. The employee works with a minimum of supervision or guidance.
Operating decisions are not subject to review on a daily basis.
Recommendations made are normally accepted with little technical review.
Completed work is reviewed in terms of overall accomplishments and the
effectiveness of the advice and assistance provided to the regional office,
contractors, intermediaries, and other involved organizations.
Factor 3 - Guidelines
Guidelines include Federal laws and regulations of the Social Security Act (Title
XVIII), CMS policy issuances and directives, and Medicare contracts. Guidelines
are usually not specific to every situation and consequently, the employee is
frequently required to adapt guidelines. Independent judgment is used in
interpreting and applying these guidelines.
Factor 4 - Complexity
The work is technical in nature. Assignments relate to a wide variety of functions
and processes under varying and changing conditions. The Medicare
regulations and policies with which the incumbent must work are limited and
related implementing policies widely dispersed and often unspecific. In addition,
these regulations and policies are subject to frequent changes and multiple,
divergent interpretations. Problems are more often than not multi-faceted.
Quality, costs, timeliness, and political acceptability must all be taken into
appropriate account when negotiating and implementing corrective actions within
the complex Medicare environment. This environment is characterized by 1) a
myriad of interrelationships among a number of key organizational components;
Central Office, other ROs. medical and other associations, the agency's
contractors, and their system subcontractors; 2) a rapidly changing legislative
component; and 3) an increasingly complex and rapidly changing electronic
claims processing technology, and 4) constant controversy. Within this
environment, the incumbent must be able to resolve problems quickly, and in a
decisive, innovative, and independent manner that results in sound, defensible
Factor 5 - Scope and Effect
This work impacts directly on the effectiveness and efficiency of Medicare
contractor operations, beneficiary service levels and program outlays, both
regionally and nationally. Decisions and technical assistance often result in
immediate changes to contractor operations, and impact on other insurers, other
agency components, subcontractors, providers, and beneficiaries. Stewardship
of vast amounts of benefit payments are involved.
Factor 6 - Personal Contacts
Contacts are with other CMS Regional and Central Office staff; with personnel
with HHS, including the Office of General Counsel, and the Office of Inspector
General; with other Federal agencies such as the U.S. Attorney's, the Federal
Bureau of Investigation and the Postal Inspectors; and with other Medicare
contractor personnel. These parties are sometimes not receptive to the agency's
Factor 7 - Purpose of Contacts
Contacts are made primarily to assess and resolve policy conflicts and
deficiencies that are often controversial or of substantial impact on program
outlays. Incumbent provides authoritative advice to CMS and contractor
personnel in the areas of policy impact and systems design. The incumbent also
testifies in court cases involving Medicare fraud and abuse.
Factor 8 - Physical Demands
Work is primarily sedentary. Minimal physical exertion is required. However,
travel is required to accomplish job functions in off-site locations that may
constitute 25 % of an employee's time.
Factor 9 - Work Environment
The work is performed in an office setting.