Appeals Review Specialist

Imagine360 is seeking an Appeals Review Specialist to join the team! This position is responsible for the review of claims from providers for possible errors to ensure plan assets are protected. 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:

• Claim edits and reviews
  
  
  
  • Verifies claim accuracy compared to medical record.
  
  
  • Reviews claims edit for fraud and abuse.
  
  
  • Escalates claims to Utilization Management Vendor when appropriate.
  
  
  
  


• Appeals/Inquiries
  
  
  
  • Reviews, researches, and responds to members and providers in writing regarding questions, complaints or denied coverage objections.
  
  
  • Provides denial explanations.
  
  
  • Responds in writing and/or via phone to all inquiries in an accurate and timely manner.
  
  
  • Trains claims employees to improve quality for reviews and appeals.
  
  
  
  


• Customer Service - Internal/External
  
  
  
  • 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.
  
  
  
  


• Sends letters to providers and members explaining a denial.
  
  
  
  • Appropriately escalates difficult issues up the chain of command.
  
  
  
  


• Quality Assurance
  
  
  
  • 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.
  
  
  • Develops new or improves current internal processes to improve quality.
  
  
  
  


• Compliance
  
  
  
  • Maintains regulatory compliance standards
  
  
  
  


• This job description in no way states or implies that these are the only duties to be performed by this employee. The employee will be required to follow any other instructions and to perform any other duties requested by his/her supervisor.

Required Experience/Education:

• HS. Diploma or equivalent


• Minimum of two years experience in claims examining or related work experience

Skills and Abilities:

• Working knowledge of computers and software including but not limited to Microsoft Office products


• Proficient 10-key and typing skills


• Demonstrated self-motivation, organizational skills, problem-solving skills


• Strong written and oral communication skills with attention to detail and accuracy


• Demonstrated ability to remain neutral and maintain confidentiality.

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**