Senior Healthcare Claims Processor

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. 

• 3-5+ 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.

• 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.

• 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