Claims Examiner

Imagine360 is seeking a Claims Examiner to join the team! The Claims Examiner properly applies plan provisions on self-funded groups and is responsible for claims processing of medical, dental and vision claims, and answers questions in accordance with relevant terms and established procedure. This individual works closely with other departments to proactively research concerns and resolve to the satisfaction of the client. This position maintains a comprehensive understanding of the plan document(s) under their scope of responsibility.
Position Location: 100% remote
Responsibilities include but are not limited to:
Claims Processing
Interprets plan documents.
Reviews, researches, and analyzes information to determine eligibility.
Processes, denies, pends, or allows claims.
Uses thought and reasoning to manage workload that carries an average level of financial risk.
Correspondence
Accurately notes the system of all information received.
Forwards all records.
Group Contacts
Tracks and returns calls and e-mails.
Answers specific plan and claim questions.
Knows each Team Member for each group.
Goes over review issues.
Appeals and Inquiries
Notes system when appeals and inquiries are received.
Records all information on appeals and inquiries in the database.
Notes system if notified that claim is going to outside review or committee
Customer Service
Acts as a role model in demonstrating the core values in customer service delivery.
Provides timely and thorough follow up with, internal and external customers.
Tracks and returns telephone calls/mail to members and groups answering specific plan/claim questions within 24 hours
Appropriately escalates difficult issues up the chain of command.
Quality Assurance
Ensures team compliance with service standards
Serves on committees, work groups, and/or process improvement teams, as assigned, to assist in improving quality/customer satisfaction.
Recognizes and alerts appropriate supervisor of trends within their scope of responsibility that fall outside of quality parameters.
Performs self-quality monitoring in order to develop and execute plans to meet established goals.
Provides ongoing feedback to help optimize quality performance.
Collaborates with others and cross-departmentally to improve or streamline procedures.
Remains current on industry trends and looks for new data sources.
Develops new or improves current internal processes to improve quality.
Required Experience/Education:
High School Diploma or GED required
Associate Degree in Medical Billing and Coding or related field preferred.
1+ years' experience in clerical and customer service required.
Claims or Medical Office experience preferred.
Knowledge of medical terminology preferred.
Skills and Abilities:
Working knowledge of computers and software including but not limited to Microsoft Office products
Proficient mathematical, 10-key and typing skills
Demonstrated organizational skills, problem-solving, analytical skills and detail oriented
Demonstrated ability to remain neutral and maintain confidentiality
Strong written and oral communication skills
Demonstrated ability to work independently, prioritize workloads multi-task and manage priorities in order to meet deadlines
What can Imagine360 offer you?
Multiple Health plan options
Company paid employee premiums for disability and life insurance
Parental Leave Policy
20 days PTO to start / 10 Paid Holidays
Tuition reimbursement
401k Company contribution
Company paid Short- & Long-term Disability plus Life Insurance
Professional development initiatives / continuous learning opportunities
Opportunities to participate in and support the company's diversity and inclusion initiatives
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Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.
Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.
**RECRUITMENT AGENCIES PLEASE NOTE: Imagine360 will only accept applications from agencies/business partners that have been invited to work on a specific role. Candidate Resumes/CV's submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable. Thank you for your cooperation**

Work arrangement
No