Program Manager

For the GS 15: You must have one full year (52 weeks) of specialized experience comparable in scope and responsibility to the GS-14 grade level or pay band in the Federal service (obtained in either the public or private sectors) performing ALL of the following: Analyzing or overseeing program integrity and compliance activities in health insurance programs to address potential fraud, waste, abuse, improper payments, program vulnerabilities or non-compliance; Coordinating program integrity, compliance, referral or corrective action activities with oversight organizations, legal counsel, contracting officials, health care organizations, carriers, or program offices; Preparing referral packages, corrective-action recommendations, recovery or disallowance analyses or contract-remedy options supported by program integrity findings; AND Developing policies, procedures, or performance measures that support the prevention, detection, and resolution of fraud, waste, abuse and payment integrity risks in health insurance programs.

You must meet all qualification and eligibility requirements by the closing date of this announcement. 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.

Direct administrative program integrity reviews involving potential fraud, waste, abuse, improper payments, control weaknesses, and other program integrity risks affecting Federal health benefits programs. Lead oversight of administrative reviews by evaluating program documentation, audit findings, referral information, claims and payment data, and other relevant materials to recommend corrective actions, recoveries, disallowances, sanctions-implementation steps, or other administrative remedy options.

Oversee health insurance carriers' compliance with contractual and regulatory requirements by directing carrier compliance reviews, validating corrective actions, and resolving program integrity findings through appropriate administrative processes. Analyze program integrity trends, claims data, audit results, carrier submissions, and risk indicators to identify vulnerabilities, improper payment risks, control weaknesses, and opportunities to strengthen fraud prevention and detection efforts.

Coordinate administrative review, referral, corrective-action, compliance, and contract-remedy activities with Offices of Inspector General, legal counsel, contracting officials, program offices, carriers, health care organizations, and other oversight partners. Develop policies, procedures, documentation standards, referral protocols, corrective-action processes, and performance measures that improve health insurance program integrity, accountability, and administrative oversight.

Supervise a multidisciplinary workforce responsible for administrative program integrity reviews, carrier compliance oversight, audit resolution, payment integrity, corrective-action monitoring, referral coordination, and contract-remedy support.