Healthcare Senior Claims Processor

At GDIT, people are our differentiator. We are seeking Healthcare Senior Claims Processors to support day-to-day medical claims operations within a Third-Party Administrator (TPA) environment serving the federally funded, limited-benefit World Trade Center Health Program.

In this role, you will review, analyze, and adjudicate professional, facility, complex, and high-dollar claims in accordance with program guidelines, regulatory requirements, and internal quality standards. You will apply strong critical-thinking skills, provide advanced technical guidance to claims staff, mentor processors, maintain strict confidentiality, mentor peers, participate in audits, and contribute to continuous improvement activities that strengthen overall claims operations performance.

The Senior Claims Processor will also ensure consistent interpretation of claim policies; and support operational readiness, training, and workflow optimization.

Responsibilities:

• Evaluate, process, and adjudicate professional, facility, complex, and high-dollar claims in alignment with program policies and federal guidelines.
• Interpret and apply reimbursement requirements, billing rules, modifiers, benefit limitations, and regulatory guidance.
• Resolve escalated claim issues, variances, exceptions, and discrepancies.
• Provide day-to-day technical expertise to claims processors on complex adjudication scenarios.
• Ensure accuracy, timeliness, and compliance with service-level requirements.
• Help define and maintain claims workflows, operating procedures, escalation paths, and quality controls.
• Translate claims policies and system rules into clear, repeatable processing instructions.
• Recommend operational improvements to increase efficiency, accuracy, and consistency.
• Assist with updates to standard operating procedures when requirements change.
• Support training programs for new and existing claims processors.
• Develop or refine job aids, desk guides, examples, and knowledge-check materials.
• Provide coaching on claims quality, system navigation, and procedural accuracy.
• Identify knowledge gaps and recommend targeted training interventions.
• Participate in claims quality reviews, calibration sessions, and root-cause analysis.
• Document claim decisions clearly and support internal and external audit requests.
• Monitor emerging trends and propose changes to training, processes, or system rules.
• Promote adherence to privacy, data security, federal requirements, and organizational policies.

Requirements:

• Minimum 5 years of hands-on experience processing medical professional and facility claims, including complex and high-dollar claims.
• Strong working knowledge of ICD-10, CPT, HCPCS, revenue codes, and modifiers.
• Understanding of the full claim’s lifecycle: intake, review, adjudication, reimbursement, adjustments, denials/rejections, and escalations.
• Demonstrated experience in interpreting and applying payer policies and federal regulations.
• Experience resolving claim denials, appeals, and complex adjudication questions.
• High accuracy in high-volume environments with strong analytical and problem-solving skills.
• Proficiency with Microsoft Office and claims processing systems.
• Ability to interpret and apply program policies, payer rules, and federal regulations.
• Commitment to ongoing training and staying current on industry standards, technology, and regulatory changes.
• Experience with claim denial resolution and appeals workflows.
• Customer-service mindset with strong analytical and problem-solving skills.