Medical Claims Auditor - Imagine360

Imagine360 is currently seeking a Medical Claims Auditor to join the team! This position audits and adjudicates stop loss insurance medical claims. Additional functions may include compiling reporting and communicating with third party administration staff.

Responsibilities include but are not limited to:

Stop Loss Claims Management

• Review medical stop loss claim submissions
• Audit claims against plan document, stop loss contract, and carrier standards
• Facilitate financing of approved claims with finance
• Pend claims and issue denials to third party administrator where appropriate
• Elevate complex claim issues for clinician or management review
• Properly documents claim file

Claim Support

• Compile periodic reporting for internal and external parties
• Advise on claim projections and development

Quality Assurance

• Recognize, document, and alert appropriate supervisor of trends in claims
• Performs self-quality monitoring in order to develop and execute plans to meet established goals
• Meet established turnaround time and accuracy metrics
• Provides ongoing feedback to help optimize quality performance
• Collaborates with others and cross-departmentally to improve or streamline procedures

Required Experience / Education:

• High School Diploma or GED required; Bachelor's degree in Medical Billing and Coding or related field preferred
• 5+ years' experience in medical claims administration (carrier or provider); Understanding of medical Third Party Administration functions preferred
• Knowledge of medical terminology required
• Working knowledge of computers and software including but not limited to Microsoft Office products
• Demonstrated organizational skills, problem-solving, analytical skills and detail oriented

What can Imagine360 offer you?

• Multiple Health Plan Options, including an Employer Paid Benefit Options
• Company paid employee premiums for Dental, Vision, STA, & LTD, plus Life Insurance
• Parental Leave Policy
• 20 days PTO to start / 10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• 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**