Healthcare Claims Supervisor

Position: Healthcare Claims SupervisorLocation: Remote, Eastern Standard Time (EST) based in the Continental United States.Reports To: Program DirectorOverview: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 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 Healthcare Claims Supervisor to support the World Trade Center Health Program Third-Party Administrator contract. Reporting to the Program Director, this position will provide daily supervisory oversight and technical leadership for a growing healthcare claims processing team. The team is expected to begin with at least two direct reports and expand as program operations grow.The Healthcare Claims Supervisor will be responsible for staff direction, claims quality, productivity, operational readiness, and consistent application of program requirements. The role requires strong knowledge of healthcare claims adjudication, coordination of benefits (COB), claims system workflows, and new program implementation. Experience using the PLEXIS claims system is strongly preferred.Duties:Team Supervision and Daily Operations

• Supervise a growing team of healthcare claims staff, with responsibility expected to expand as claim volumes increase.
• Provide daily work direction, assign priorities, balance workloads, monitor queues, and ensure timely completion of claims processing activities.
• Conduct regular individual and team check-ins, provide coaching, communicate expectations, and address operational barriers.
• Monitor attendance, productivity, quality, accuracy, and adherence to established procedures and performance expectations.
• Escalate staffing, performance, system, policy, or operational risks to the Program Director with recommended corrective actions.
• Support employee onboarding, cross-training, knowledge development, and succession planning as the team expands.

Claims Processing and Technical Oversight

• Provide supervisory and technical oversight for end-to-end healthcare claims intake, review, adjudication, payment, denial or rejection, adjustment, and escalation processes.
• Serve as an operational subject matter expert for complex claims, claim edits, exceptions, reimbursement questions, and processing issues.
• Ensure consistent interpretation and application of program requirements, benefit rules, covered conditions, reimbursement guidance, and claims processing procedures.
• Review and help resolve complex or escalated claims issues using applicable policies, procedures, system information, and supporting documentation.
• Partner with program leadership and cross-functional stakeholders to address recurring claim issues and improve processing consistency.

Coordination of Benefits

• Oversee coordination of benefits processing, including primary and secondary payer determination, Medicare coordination, Other Health Insurance (OHI), workers compensation coordination, and related recovery activities.
• Ensure COB claims are processed in accordance with program rules, payer order requirements, available remittance information, and established procedures.
• Provide guidance on complex COB scenarios, payment calculations, duplicate coverage, liability considerations, and claims requiring additional information.
• Identify COB-related trends, errors, and training needs, and recommend procedural or system improvements.

New Program Implementation and Operational Readiness

• Support the design, implementation, and startup of new healthcare claims operations and major program changes.
• Participate in business requirements reviews, workflow design, claims scenario development, user acceptance testing, defect triage, operational readiness reviews, and go-live support.
• Help establish staffing plans, work assignments, escalation paths, quality controls, productivity expectations, and standard operating procedures for new operations.
• Validate that claims workflows and system configurations support program requirements, business rules, benefit limitations, COB requirements, and operational expectations.
• Identify implementation gaps, dependencies, and risks and communicate recommended solutions to the Program Director.

PLEXIS System and Workflow Support

• Use the PLEXIS claims system, or comparable claims administration technology, to support daily claims operations, queue management, issue research, and staff guidance.
• Assist with system workflow validation, claims testing, edit review, defect documentation, and confirmation that approved fixes operate as intended.
• Coordinate with technical and operational stakeholders to resolve system issues affecting claims processing, COB, quality, or productivity.
• Document system workarounds, known issues, and processing guidance until permanent solutions are implemented.

Quality, Compliance, and Continuous Improvement

• Conduct or oversee claims quality reviews, calibration sessions, root cause analysis, corrective actions, and focused retraining.
• Monitor operational trends, error patterns, inventory, aging, and recurring issues to identify opportunities for process, training, staffing, or system improvement.
• Promote compliance with contract requirements, privacy and security obligations, J29 policies, and program-specific procedures.
• Maintain audit-ready documentation and support operational reporting requested by the Program Director.
• Promote 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.
• 3+ years of experience supervising or formally leading claims processors, examiners, analysts, or comparable healthcare operations staff.
• Demonstrated experience managing team productivity, quality, workload distribution, coaching, accountability, and operational performance.
• Strong working knowledge of the end-to-end healthcare claims lifecycle, including intake, review, adjudication, reimbursement, adjustments, denials or rejections, and escalation handling.
• Demonstrated experience with coordination of benefits, including primary and secondary payer rules, Medicare coordination, Other Health Insurance (OHI), workers compensation coordination, and recovery processes.
• Experience supporting new program implementations, operational startups, claims system implementations or upgrades, process redesign, operational readiness, user acceptance testing, and go-live activities.
• Experience developing, implementing, or maintaining claims processing SOPs, workflows, desk procedures, job aids, quality controls, and training materials.
• Ability to analyze complex claims and operational issues, interpret requirements, document decisions, and communicate clear direction to staff and stakeholders.
• Strong independent problem-solving, organization, leadership, and time management skills in a fully remote environment.
• Proficiency with Microsoft Excel, Word, Teams, Outlook, SharePoint, and other collaboration or reporting tools.

Preferred Experience:

• Hands-on experience with the PLEXIS claims system, including claims processing, workflow navigation, issue research, testing, or operational support.
• Experience supporting a limited health benefit, specialty benefit, occupational health, workers compensation, Federal healthcare, 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, provider reimbursement, appeals, payment integrity, prior authorization, claims quality, or auditing.
• Knowledge of healthcare electronic transactions and files, including 834, 835, and 837 transactions, and a general understanding of file transfer processes.
• Experience with PLEXIS and one or more additional claims payment, adjudication, workflow, or case management systems, such as Facets, QNXT, HealthRules, NASCO, or TriZetto platforms.
• Working knowledge of medical coding, including ICD-10, CPT, HCPCS, revenue codes, modifiers, and the effect of coding on claim payment and authorization decisions.
• Experience with claims reporting, operational dashboards, service-level agreement tracking, root cause analysis, SQL, Power BI, or comparable reporting tools.
• Healthcare claims, coding, billing, auditing, health information management, or related industry certification.

Education:

• Bachelor’s degree in business administration, healthcare administration, public policy, or a related field is required. Relevant additional experience may be considered in accordance with company requirements.
• Claims-related certifications or training are preferred.

Salary: $62,000-72,000J29, 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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