The Claims Analyst performs medical record and claims reviews to ensure compliance and identify potential fraud, waste, or abuse. They also manage pharmacy service contracts, lead assigned tasks, and provide clinical expertise to support project goals.
Position: Claims Analyst III Location: Remote
About J29 J29 is an employee centered healthcare management consulting company that specializes in processing, reviewing, and analyzing medical 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 that stretches to various areas where we can provide our clinical, healthcare policy, and compliance expertise through our support to health and human service programs at the State, Federal, and Commercial levels. Overview Performs medical record and claims review for Medicare, Medicaid, and/or other claims data in order to ensure that proper guidelines have been followed and assesses for potential overpayment, fraud, waste, and abuse with regards to Medicare, Medicaid, and/or other claims.
Role & Responsibilities
Facilitates and manages assigned projects and contracts relating to pharmacy services. Leads and provides oversight to assigned tasks and contracts, making sure that contract specifications are understood, tasks are assigned appropriately, and information is available and circulated.
Prioritizes and accomplishes tasks and programs independently and in a team to ensure successful implementation of goals and objectives.
Works with the appropriate stakeholders to build partnerships, support data sharing, and develop tools and references to support changes in care practices in the pharmacy arena.
Reviews and interprets contract deliverables to ensure timely and accurate completion.
Contributes to the conceptual design and implementation of projects, as well as assists with project execution as needed.
Ensures all project deliverables and timelines are met and reports on variances in a timely manner.
Testifies at various legal proceedings or administrative hearings, when subpoenaed.
Provides educational programs, as necessary, to meet project goals. Contributes professional presentations at pharmacy, medical, and quality organization meetings.
Experience / Expertise
Requires 5-7 years work experience (this could be a combination of clinical and utilization review, case management, etc.) 8-11 years preferred.
Must hold a current, active RN license issued by the state board of nursing. Compliance with all regulatory standards and ability to maintain licensure throughout employment is required.
BSN degree is strongly preferred to ensure advanced clinical knowledge and leadership skills. Candidates with an Associate Degree in Nursing (ADN) will be considered if they demonstrate equivalent experience and commitment to continuing education.
Coding certification preferred
Demonstrates strong analytical skills and the ability to make sound, timely decisions.
Proven ability to work effectively within diverse teams and foster a cooperative environment.
Embraces continuous learning, adaptability, and supports the development of self and others.
Skilled in planning, organizing, and delivering results while ensuring quality and support throughout processes.
Proficient in using digital tools and technologies to enhance efficiency and communication.
General Physical Requirements: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
J29, Inc. is committed to hiring and retaining a diverse workforce. We are proud to be an Equal Opportunity/Affirmative Action Employer, making decisions without regard to race, color, religion, creed, sex, sexual orientation, gender identity, marital status, national origin, age, veteran status, disability, or any other protected class. J29, Inc. is a proud Veteran friendly employer.
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