The Senior Claims Operations Lead will define and document claims workflows, standard operating procedures, and operational readiness plans for the World Trade Center Health Program. They will also provide technical subject matter expertise, mentor claims processors, and support quality improvement initiatives.
Position: 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:
Claims Implementation and Operational Readiness
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 documentation requested by the Project Manager.
Contribute to a collaborative, accountable, and continuous-improvement culture within a fully remote team.
Experience:
8+ years of healthcare claims processing, adjudication, reimbursement, payment integrity, claims review, or related healthcare claims operations experience.
Demonstrated experience developing or implementing SOPs, workflows, desk procedures, job aids, or training materials.
Experience supporting claims operations implementation, process design, operational readiness, system conversion, or major workflow change.
Experience serving as a senior claims processor, lead, trainer, mentor, analyst, or subject matter expert for other claims staff.
Strong understanding of the end-to-end healthcare claims lifecycle, including claims intake, review, adjudication, reimbursement, adjustments, denials or rejections, and escalation handling.
Ability to analyze complex claims issues, interpret requirements, document decisions, and communicate clear operational guidance.
Strong independent problem-solving, organization, and time management skills in a fully remote environment.
Proficiency with Microsoft Excel, Word, Teams, Outlook, SharePoint, and other collaboration or reporting tools.
3-5+ years of experience leading claims supervisors, examiners, analysts, operational teams, or claims quality programs, including responsibility for productivity, performance, and accountability initiatives.
3-5+ years of direct involvement in claims system implementations, upgrades, process redesign, operational readiness, business requirements gathering, user acceptance testing, and defect triage, resolution, and validation.
3+ years of client-facing experience participating in operational review meetings, resolving issues, managing stakeholder expectations, and presenting performance results, risks, and recommendations.
Strong working knowledge of provider reimbursement methodologies, claims quality review, auditing, appeals, reconsiderations, operational metrics, reporting, workflow management, and payment accuracy programs.
Working knowledge of claims reporting, operational dashboards, service-level agreement tracking, root cause analysis, and Microsoft Excel.
Preferred Experience
Experience supporting a limited health benefit program, specialty benefit program, occupational health program, workers compensation program, or other program in which coverage is tied to defined eligibility and covered conditions.
Experience with Medicare, Medicaid, commercial payer, Federal healthcare, or third-party administrator claims operations.
Experience with benefit configuration, coordination of benefits, provider reimbursement, appeals, payment integrity, or claims quality.
Knowledge of healthcare electronic transactions and files, including 834, 835, and 837 transactions, and a general understanding of file transfer processes.
Experience with more than one claims payment, adjudication, workflow, or case management system.
Healthcare claims, coding, billing, auditing, health information management, or related industry certification.
3-5+ years of medical coding knowledge preferred, including ICD-10, CPT, HCPCS, revenue codes, modifiers, medical necessity concepts, and the effect of coding on claim payment and authorization decisions. Professional coding certification is a plus but is not required.
Strong understanding of prior authorization workflows, referral management, medical necessity review, clinical documentation requirements, and authorization-related claim edits.
Experience with coordination of benefits, including primary and secondary payer rules, Medicare coordination, Other Health Insurance (OHI), workers compensation coordination, and recovery processes.
Experience with PLEXIS, Facets, QNXT, HealthRules, NASCO, TriZetto platforms, or other healthcare claims processing systems.
Experience with SQL, Power BI, or comparable data analysis and reporting tools.
Education:
Bachelor’s degree in business administration, healthcare administration, public policy, communications, technical writing, or a related field is required.
Claims related certifications or trainings, preferred
Salary: $32,000-42,000
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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