RN Healthcare Claims Examiner
NCTracks was implemented in July 2013 and used by the Division of Medical Assistance (DMA); the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (DMH/DD/SAS); and the Division of Public Health (DPH). GDIT is the fiscal agent for NC DHHS and handles the daily operations and functionality enhancements to NCTracks.
Providers enrolled in DMA, DMH/DD/SAS and DPH health plans submit claims for payment of covered health care services through the NCTracks Provider Portal. NCTracks coordinates processing among the payers to ensure the proper assignment of the payer, benefit plan and pricing methodology for each service on a claim. NCTracks processes health care claims, prior approval requests, provider enrollment, finance, and other healthcare transactions.
A licensed nurse is needed as a Healthcare Claims examiner associate to ensure that the team meets the SLA by meeting quantity performance standards of least 35 reviews each day and overall performance expectations:
- Analyzes durable medical equipment (DME) prior approval requests for NC Medicaid to ensure compliance with clinical guidelines
- Performs review of documentation submitted prior approval requests for DME services to determine if the recipient is eligible for the services being requested
- BSN + 3 yrs related experience, or MSN + 1 yr related experience
- Requires active NC license as Registered Nurse (in good standing)
- Ability to work independently to meet individual performance standards
- Must be comfortable with using a computer
- Knowledge of Microsoft Office and Outlook
- Prefer to have knowledge of NC Tracks
- Prefer to have knowledge of business processes of NC DHHS and/or NC Health Choice
- Prefer experience with DME
THIRD PARTY AGENCIES, SUBCONTRACTORS, AND RECRUITERS NEED NOT APPLY. Applicants received from firms will not be considered. Subcontracting is not available for this position.
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