Nurse

Summary This position is within the Department of Health & Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), Center for Program Integrity, Data Analytics & Systems Group, Division of Modeling & Analytics (DMA). As a Nurse, GS-0610-13, you'll offer clinical guidance to CMS policy teams on complex Medicare/Medicaid issues and serve as a resource for beneficiaries, providers, and contractors regarding clinical questions and program protection. Responsibilities Apply a wide range of software, systems, and analytical platforms to identify overpayments and detect fraud/abuse across Medicare, Medicaid, and the Children’s 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 Officer's 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. Requirements Conditions of Employment Qualifications 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, bachelor's 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 Examination. In 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. Minimum Qualifications, GS-13: In addition to the mandatory license and education described above under Basic Requirements applicants 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; and (4) 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. Education Education Requirement: In addition to meeting the qualification requirements, all candidates must have the following educational requirements: A graduate or higher-level degree, bachelor's 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 Examination. In 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. TRANSCRIPTS are required to verify satisfactory completion of the educational requirement listed above. Please see "Required Documents" section below for what documentation is required at the time of application. Click the following link to view the occupational questionnaire: Additional Information THIS SERVES TO AMEND THE SALARY TO READ: $121,785 - 158,322; the closing date of this position to read: August 7, 2026; and an update to the Job Summary of this position. Bargaining Unit Position: Yes - American Federation of Government Employees Tour of Duty: Flexible Recruitment Incentive: Not Authorized Relocation Incentive: Not Authorized Financial Disclosure: Not Required 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