Senior Healthcare Claims Processor

Senior Healthcare Claims Processor

Location:

Remote, Eastern Standard Time (EST) based in the Continental United States.

Reports To:

Program Director

Overview: J29 is an employee centered health and human service management consulting company that specializes in processing, reviewing, and analyzing claims, records, disputes, and audits. Established in 2017, J29 prides itself on its employee centric culture and high employee retention rates that allow us to ensure that we are creating a working environment that prioritizes the employee experience. Our team brings corporate performance where we provide our clinical, healthcare policy, and compliance expertise through our support to health and human service programs.

J29 is seeking an experienced Claims Operations Lead to support the World Trade Center Health Program Third-Party Administrator contract. Reporting to the J29 Project Manager, this position serves as a senior operational and technical subject matter expert for healthcare claims processing. The Senior Claims Operations Lead will help establish standard operating procedures, define and document claims processes, support operational implementation and readiness, and provide lead-level claims expertise to healthcare claims processors.

The role will translate program requirements and claims policies into practical workflows, training materials, quality controls, and daily operating procedures. This position is one level below the Healthcare Claims Project Manager and does not own overall project budget, client management, or contract delivery.

Duties:

• Support the J29 Project Manager with the implementation and startup of healthcare claims operations.
• Help define end-to-end claims workflows, operating procedures, handoffs, escalation paths, and controls.
• Participate in requirements reviews, workflow design sessions, operational readiness reviews, user acceptance testing, claims scenario testing, and go-live support.
• Validate that documented claims processes align with applicable program requirements, business rules, benefit limitations, and operational expectations.
• Identify implementation gaps, operational risks, and process dependencies and elevate them to the Project Manager with recommended solutions.

SOP and Process Development

• Develop, document, implement, and maintain claims processing standard operating procedures, workflows, desk guides, job aids, and reference materials.
• Translate claims policies, reimbursement requirements, system rules, and client direction into clear and repeatable processor instructions.
• Define procedures for claims intake, review, adjudication, pend and reject handling, adjustments, escalations, and quality review, as applicable to the program.
• Assess existing workflows and recommend practical improvements that strengthen accuracy, timeliness, consistency, and compliance.
• Maintain version control and support timely updates to procedures when program or system requirements change.

Lead Claims Subject Matter Expertise

• Serve as an additional lead-level claims SME for healthcare claims processors and other operational team members.
• Provide day-to-day technical guidance on complex claims, exceptions, edits, payment questions, and processing requirements.
• Research and help resolve escalated claims issues using applicable procedures, benefit rules, reimbursement guidance, and system information.
• Support consistent interpretation and application of claims processing requirements across the team.
• Partner with the Project Manager and cross-functional stakeholders to resolve recurring operational issues.

Training and Processor Support

• Support onboarding, training, mentoring, and ongoing knowledge development for healthcare claims processors.
• Create or refine training content, claims examples, knowledge checks, job aids, and refresher materials.
• Provide individual and group coaching on procedures, claims quality, system use, and complex processing scenarios.
• Identify knowledge gaps or recurring errors and recommend targeted training or procedural clarification.

Quality, Compliance, and Continuous Improvement

• Support claims quality reviews, calibration activities, root cause analysis, and corrective action efforts.
• Monitor claims trends and recurring issues to identify opportunities for procedural, training, system, or workflow improvement.
• Promote compliance with contract requirements, privacy and security obligations, J29 policies, and program-specific procedures.
• Assist with audit readiness, operational reporting, and…