Healthcare Claims Processor

Position: Healthcare Claims Processor
Location: Remote, Eastern Standard Time (EST) based in the Continental United States.
FLSA Status: Non-Exempt, Full-Time
Reports To: Claims Supervisor

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 a Junior Healthcare Claims Analyst/Adjudicator to support healthcare claims operations. This entry-level to early-career position is responsible for reviewing and processing healthcare claims in accordance with established procedures, benefit requirements, system rules, and quality standards.

The Junior Healthcare Claims Analyst/Adjudicator will complete routine claims processing activities, verify claim and member information, review claims for completeness and accuracy, apply documented processing rules, and escalate exceptions or complex issues to senior team members. The position does not require supervisory, leadership, or client-facing experience. The successful candidate will be detail-oriented, dependable, comfortable working in a structured production environment, and willing to learn specialized benefit and claims processing requirements.

Duties:

Claims Review and Adjudication

• Review professional, institutional, and other healthcare claims for completeness, accuracy, and compliance with established procedures.
• Verify member eligibility, dates of service, provider information, billed services, authorization information, and other required claim data.
• Apply documented benefit rules, reimbursement guidelines, system edits, and processing instructions to adjudicate claims accurately.
• Process routine claims, adjustments, corrections, pends, denials, and rejections within assigned authority and training.
• Identify missing, conflicting, or incomplete information and follow established procedures to resolve or escalate the issue.
• Review claim history and available supporting documentation before making or recommending a processing decision.
• Document claim actions, research, and processing decisions clearly in the applicable system.

Claims Research and Issue Resolution

• Research routine claim edits, payment questions, duplicate claims, eligibility issues, authorization requirements, and coding-related discrepancies.
• Compare claim information with available benefit, eligibility, authorization, provider, and payment records.
• Use desk guides, standard operating procedures, system references, and other approved resources to resolve assigned claims.
• Escalate complex claims, unclear requirements, unusual billing situations, and potential system defects to senior analysts or supervisors.
• Respond promptly to requests for additional information or correction of processing errors.
• Support claim reprocessing activities when corrections or adjustments are required.

Quality, Accuracy, and Productivity

• Meet established expectations for claim accuracy, productivity, timeliness, and documentation.
• Review work carefully before finalizing claim decisions.
• Participate in quality reviews, feedback sessions, refresher training, and corrective action activities.
• Apply feedback from quality reviewers, trainers, and supervisors to improve individual performance.
• Notify the supervisor or lead when recurring issues, unclear instructions, or potential process gaps are identified.
• Maintain accurate records of assigned work and completed activities.

Training and Operational Support

• Complete required claims processing, system, privacy, security, and program-specific training.
• Learn and consistently follow standard operating procedures, desk guides, job aids, and escalation protocols.
• Participate in claims scenarios, system testing, workflow exercises, and readiness activities when requested.
• Ask questions and seek guidance when processing requirements are unclear.
• Maintain current knowledge of procedural and system updates communicated by management.
• Support team workload priorities and assist with additional claims-related assignments as needed.

Compliance and Information Protection

• Protect confidential member, patient, provider, and claims information.
• Follow applicable privacy, security, records-management, and information-handling requirements.
• Process claims objectively and consistently using approved procedures and available documentation.
• Immediately report suspected privacy incidents, data concerns, payment discrepancies, or potential fraud, waste, or abuse through established channels.
• Maintain a secure and professional remote work environment.

Experience:

• One to three years of experience in healthcare claims processing, medical billing, provider billing, health insurance operations, healthcare administration, data entry, customer service, or a related field is preferred.
• Previous healthcare claims adjudication experience is helpful but not required for candidates with relevant healthcare operations or medical billing experience.
• Basic understanding of the healthcare claims lifecycle, including claim submission, review, payment, denial, rejection, adjustment, and escalation.
• Ability to follow detailed written procedures and apply established rules consistently.
• Strong attention to detail and commitment to accurate data entry and documentation.
• Ability to identify incomplete or inconsistent information and escalate questions appropriately.
• Basic analytical, research, organization, and time-management skills.
• Ability to work independently after training while remaining receptive to guidance and quality feedback.
• Ability to manage assigned work and meet production and turnaround-time expectations in a remote environment.
• Clear written communication skills for documenting claim actions and questions.
• Basic proficiency with Microsoft Excel, Word, Teams, Outlook, and other computer-based systems.
• Ability to learn healthcare claims systems and work efficiently across multiple screens or applications.
• No supervisory, team-lead, or formal client-facing experience is required.

Preferred Experience

• Experience with Medicare, Medicaid, commercial insurance, third-party administrator, workers’ compensation, occupational health, or specialized health benefit claims.
• Familiarity with professional or institutional healthcare claims.
• General knowledge of ICD-10, CPT, HCPCS, revenue codes, modifiers, and medical billing terminology.
• Familiarity with eligibility verification, prior authorization, referrals, coordination of benefits, or provider reimbursement.
• Experience using a healthcare claims processing, medical billing, electronic health record, workflow, or case-management system.
• Familiarity with electronic healthcare transactions, including 835 and 837 files.
• Experience reviewing medical bills, explanations of benefits, remittance information, or claim status information.
• Healthcare claims, medical billing, coding, health information management, or related training or certification.

Education:

• High school diploma or equivalent is required.
• Associate degree, bachelor’s degree, or coursework in healthcare administration, business administration, medical billing, health information management, or a related field is preferred.
• Relevant healthcare claims, billing, coding, or insurance experience may substitute for postsecondary education.
• Claims-related certification or training is preferred but not required.

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.

Originally posted on Himalayas