Auto Adjudication Specialist

Position Location: 100% Remote

Responsibilities include but are not limited to:

• Reviews daily auto adjudication reports.
• Collaborates with Claims, Configuration and IT to identify solutions to increase auto adjudication percentages.
• Works with Claims, IT and Configuration teams to analyze current AA process and solutions.
• Reviews reports and audits claims following system changes implemented to ensure claims are adjudicating correctly.
• Collaborates with staff and cross-departmentally to improve or streamline procedures.
• Collaborates with IT, Claims and Configuration to identify and develop new logic for auto-adjudication.
• Performs self-quality monitoring in order to develop and execute plans to meet established goals.
• Provides ongoing feedback to help optimize quality performance.
• Assists the Claim Department in performing plan design testing for new clients and renewing clients to assure quality output from the system.
• Ultimately responsible for the increase in AA throughput and claims processing.
• Acts as a role model in demonstrating the core values in AA Claims delivery.
• Provides timely and thorough follow up with, internal and external customers.
• Appropriately escalates difficult issues up the chain of command.
• Provides back-up to the department and specialized functions as needed.
• Ensures team compliance with service standards as they specifically relate to claims auto adjudication.
• 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 and other parameters.
• Remains current on industry trends and looks for new data sources.

Required Experience / Education:

• High School Diploma or equivalent required.
• Associates Degree or equivalent experience preferred.

• 3 years of Claims Examiner and/or plan building experience required.
• Medical Coding experience preferred.
• Familiarity with GBAS system and/or Javelina and experience with auto-adjudication processes preferred.

What can Imagine360 offer you?

• Multiple Health Plan 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**