Healthcare Claims Examiner
About the role
As a Healthcare Claims Examiner at GDIT, you will support the mission of public health, life science, and clinical research by performing prior approval reviews under the private duty nursing and durable medical equipment programs. You will reference the Division of Health Benefits (DHB) Clinical Coverage Policy and use the NCTracks system to adjudicate requests, meet GDIT’s service level agreement (SLA) of 20‑30 reviews per day, and achieve quality review expectations on at least 95% of cases each month. The role requires clear written denial summaries and additional information requests, and calls for strong organizational, analytical, decision‑making, and leadership skills. You will collaborate with team members, drive corporate goals, and utilize DHB policies and NCTracks to determine the appropriate level of services for prior approval requests.
Responsibilities
- Perform prior approval reviews for private duty nursing and durable medical equipment programs.
- Apply DHB Clinical Coverage Policy and utilize the NCTracks system.
- Meet GDIT’s SLA of 20‑30 reviews per day.
- Achieve quality review standards on ≥95% of cases reviewed monthly.
- Prepare clear written denial summaries and additional information requests.
- Collaborate with team members and drive corporate goals.
- Utilize DHB policies and NCTracks to determine service levels for