Nurse

• Apply a wide range of software systems and analytical platforms to identify overpayments and detect fraud/abuse across Medicare Medicaid and the Childrens Health Insurance Program (CHIP).
• Develop algorithms/models conducting data mining and providing clinical and analytical decision support to improve the efficiency and effectiveness of program integrity operations.
• Review Federal laws regulations and procedural guidelines to advise leadership on technical flaws and regional impacts of proposed policy changes.
• Develop guidelines and procedures for reviewing clinical data to determine whether beneficiaries are receiving medically necessary care at appropriate levels of service.
• Utilize nursing expertise to refine or develop implementing regulations and methods for addressing healthcare coverage and payment determinations.
• Maintain a comprehensive outreach/education program to ensure Medicare contractors beneficiaries families Congressional representatives and community-based partners are informed of program benefits rights and responsibilities.
• Determine training needs develop/conduct regional training for Medicare contractor staff and serve as a Business Functional Lead Contracting Officers Representative (COR) or Government Task Lead (GTL) over contracts and task orders.
• Represent CMS at meetings seminars conferences and before health organizations professional panels and special interest groups on issues related to program vulnerabilities fraud/abuse detection and clinical nursing concerns.
• Speak on behalf of CMS leadership prepare/present papers briefing materials and findings to promote understanding and acceptance of Agency policies at both the regional and national level.

• 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.
• One-year probationary period may be required.
• If you are selected for this position the documentation that you present for purposes of completing the Department of Homeland Security (DHS) Form I-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 a financial institution of their choice.
• Selective Service: Males born after December 31 1959 must be registered or exempt from Selective Service -

ALL QUALIFICATION REQUIREMENTS MUST BE MET WITHIN 30 DAYS OF 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 being considered further.

Applicants must demonstrate that they meet the Basic Requirements as noted below.

Education: A graduate or higher-level degree bachelors degree associate degree or diploma from an accredited professional nursing educational program is required. This education must have been accredited by the Commission on Collegiate Nursing Education Council on Accreditation of Nurse Anesthesia Educational Programs Accreditation Commission for Midwifery Education or an accrediting body recognized by the U.S. Department of Education at the time the degree was obtained; OR a Degree from Foreign Nursing School: Official certification from the Commission on Graduates of Foreign Nursing Schools is required for individuals who graduated from foreign nursing schools.

Licensure: For all grade levels and positions applicants must have passed the National Council Licensure addition they must possess a current active full and unrestricted license or registration as a professional nurse from a State the District of Columbia the Commonwealth of Puerto Rico or a territory of the United States.

Exemption: Employees currently assigned to positions in this occupational series as of September 2017 will be considered to have met the basic requirements for the position occupied.

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) Serving as a Registered Nurse (RN) conducting medical necessity reviews for Medicare fee-for-service claims;
(2) Conducting quantitative analysis related to potential fraud waste and abuse associated with the administration of organizational and/or other government administered programs;
(3) Tracking data from existing reporting systems to monitor program integrity metrics;
(4) Ensuring clinic operations comply with The Joint Commission (TJC) standards and that the organization maintains a standard of quality care; AND
(5) Reviewing Federal laws regulations and procedural guidelines to advise leadership on technical flaws and regional impacts of proposed policy changes.

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 or former Federal employees and current or former Federal employees applying under the VEOA eligibility who hold or have held a permanent General Schedule position in the previous year 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.

Required Experience:

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