Healthcare Claims Examiner

General Dynamics Information Technology and CSRA have united to create the premier provider of high-tech IT solutions to the government IT market. Together as General Dynamics Information Technology, we deliver cost-effective, next-generation IT solutions and services to the Department of Defense, the intelligence community and federal civilian agencies as they modernize their information systems.

GDIT is currently seeking a Healthcare Claims Examiner in Raleigh, North Carolina to join our team. In this role you will be a change agent by evaluating the appropriateness of beneficiaries' admission to nursing facilities; evaluating the medical necessity of surgical and medical prior approval request, which may include transplants, out-of-state evaluations and surgeries. .

RESPONSIBILITIES:

• Verify receipt of documentation that supports the medical necessity of prior approval requests for admission into a long term care facility
• Evaluate accuracy and timeliness of documentation submitted for prior approval requests for surgeries and medical care
• Meet daily expected performance expectations by completing at least 30 prior approval reviews daily
• Meet quality expectations of greater than 95% accuracy on quality assurance reviews
• Meet service level agreement of timely reviews by completing the reviews within 24 -72 hours
• Meet timely updating of the system with prior approval decisions within 7 business days.

QUALIFICATIONS:

Required Skills and Experience - 

• Requires active North Carolina Registered nurse license or Compact license with at least 2 years of clinical experience in long term care and medical/surgical care
• Knowledge of Microsoft Office and Outlook
• Experience with medical documentation and reviews

• 3-5 Years of work experience

Desired Skills and Experience:

• Prefer to have knowledge of NCTracks
• Prefer to have knowledge of business processes of North Carolina Division of Medicaid
• Prefer clinical medical, surgical and nursing facility experience
• Prefer clinical research experience  

ATTRIBUTES FOR SUCCESS:

• Ability to utilize professional knowledge, judgement and skills in the application of Policy guidelines
• Ability to analyze processes and contribute to improvements
• Comfortable with technology and changes in technology
• Strong verbal and written communication skills

As a trusted systems integrator for more than 50 years, General Dynamics Information Technology provides information technology (IT), systems engineering, professional services and simulation and training to customers in the defense, federal civilian government, health, homeland security, intelligence, state and local government and commercial sectors. With approximately 32,000 professionals worldwide, the company delivers IT enterprise solutions, manages large-scale, mission-critical IT programs and provides mission support services. GDIT is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status, or any other protected class.