Imagine360 is currently seeking a Claims Examiner! This Claims Examiner properly applies plan provisions on self-funded groups. This position is responsible for claims processing of medical, dental and vision claims, and answers questions in accordance with relevant terms and established procedures. 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

REQUIRED EXPERIENCE / EDUCATION:

• High school diploma or GED
• 1+ years’ experience in clerical and customer service positions

PREFERRED EXPERIENCE / EDUCATION:

• Associate degree in Medical Billing and Coding or related field
• Claims or Medical Office experience. Knowledge of medical terminology.
• TPA experience

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

• 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.
• Identify and investigate suspicious claims to prevent fraud and abuse.
• Responsible for meeting or exceeding production and quality standards.
• Research, resolve and respond to inquiries and problems of a moderately complex nature.
• Follow documented claims policies and procedures
• Interface with other departments, when necessary, regarding claims issues.
• Participate in Claims Department staff meetings, and other activities as needed.
• Correspondence
• Accurately notes the system of all information received.