Healthcare and Insurance - Ancillary Benefits, Compliance, and Performance (ABCP)- Contract Administration and Program Support

• Reviews and analyzes evidence submitted by health plans applying for participation in the Federal Employees Health Benefits (FEHB) Program for compliance with the law, regulations, and office policies.• Advises carriers on difficult enrollment problems and on changes in the law and regulations.• Plans and conducts post-award conferences to ensure compliance with, and full understanding of, contractual requirements and to preclude unauthorized changes or alterations in contract provisions.• Monitors contractors' performance and solves problems associated with contract disputes.• Conducts regular on-site health plan visits to assess overall operations such as the claims processing procedures, coordination of benefits, customer service, etc.• Educates new carriers to the FEHB program on available resources such as program policies and regulations.• Explains the benefit negotiation cycle, process and format for submitting proposals, and due dates.• Reviews and approves or rejects changes carriers have made to the online FEHB system with benefits and guide information that includes any changes in co-pays, service areas, or plan contact information.• Assists the Office of the Inspector General (OIG) with obtaining information from carriers to be used in conducting periodic audits.

• Review disputed health benefit claims for plans in the Federal Employees Health Benefit (FEHB) program to determine if the carriers’ actions are in accordance with provisions of the contract between OPM and the carrier as well as the regulations of the FEHB program, Federal Employees Health Benefits Acquisition Regulations (FEHBAR), and the Federal Acquisition Regulation (FAR). • Extensive knowledge of regulations and interpretation to analyze and resolve complex disputed health claims and/or appeals.• Experience with and knowledge of the health benefits, insurance industry and consult with internal clinical advisors for accuracy related to clinical information.• Apply knowledge of group health benefits and insurance regulations, policies, and procedures in the administration of large health benefit programs by ensuring health plans’ claim processing systems are in accordance with regulations, policies, and procedures in the administration of plans.• Knowledge and understanding of FEHB program benefits, guidelines, rules, policies and regulations including but not limited to federal and state level mandates• Analyze and respond to inquiries submitted by enrollees via telephone, mail or in person on FEHB contracts, regulations and the administration of the Federal Employee Health Benefit (FEHB) program as it pertains to policies and requirements per the FAR, FEHBAR and the FEHB program.