Claims Examiner

About the Role

Imagine360 is hiring a Claims Examiner to remotely handle claims processing for self-funded group plans, including medical, dental, and vision claims. This role requires applying plan provisions accurately, collaborating with other departments to resolve client concerns, and maintaining in-depth knowledge of assigned plan documents.

Key Responsibilities

• Process claims by interpreting plan documents and determining eligibility through thorough research and analysis.
• Decide on claims by processing, denying, pending, or approving them based on an understanding of plan provisions.
• Accurately document all received information and forward relevant records.
• Maintain communication with group contacts by tracking and responding to calls and emails, addressing specific plan and claim inquiries.
• Monitor and document appeals and inquiries, including any involvement with external reviews or committees.
• Provide exceptional customer service by demonstrating company values, performing timely follow-ups with members and groups within 24 hours, and escalating complex issues appropriately.
• Ensure adherence to team service standards and participate in quality assurance activities such as committees, work groups, and process improvement initiatives.
• Identify and report trends outside quality parameters, perform self-quality monitoring, and provide feedback to optimize performance.
• Collaborate with various departments to enhance and streamline procedures, stay updated on industry trends, and develop or improve internal processes for quality improvement.

Required Qualifications and Experience

• High school diploma or GED mandatory; associate degree in medical billing, coding, or a related field preferred.
• At least one year of clerical and customer service experience required; claims or medical office experience is preferred.
• Familiarity with medical terminology is advantageous.

Skills and Abilities

• Competency in computer and software use, especially Microsoft Office suite.
• Proficient in mathematics, 10-key operation, and typing.
• Strong organizational, analytical, and problem-solving skills with close attention to detail.
• Ability to maintain neutrality and confidentiality.
• Effective verbal and written communication capabilities.
• Capability to work independently, prioritize tasks, multitask, and meet deadlines efficiently.

Benefits and Perks

• Various health insurance plan options.
• Employer-covered premiums for disability and life insurance.
• Parental leave policy.
• Starting with 20 days paid time off plus 10 paid holidays.
• Tuition reimbursement program.
• 401(k) plan with company contributions.
• Company-funded short-term and long-term disability plus life insurance coverage.
• Opportunities for professional development and ongoing learning.
• Participation in and support for company diversity and inclusion efforts.

Additional Information

Imagine360 offers an innovative health plan solution combining over five decades of experience in self-funded healthcare, helping employers save substantially on healthcare costs. This organization values equal employment opportunities and considers all qualified candidates irrespective of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.

Note for recruitment agencies: Only authorized agencies invited to apply for this role will be accepted. Unsolicited candidate submissions to hiring managers are not eligible for fees.