Experienced Managed Care Claims Examiner

🕒 June 5

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

📋 Claims Specialist

👻 Ghost score 65%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Imagenet LLC

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

📦 Logistics

📣 Marketing

💰 Private Equity Round on 2022-12

Healthcare • Logistics • Marketing

Imagenet LLC is a leading provider of business continuity services for healthcare organizations, specializing in digital mailroom solutions, claims adjudication, contact center operations, and workflow management. With over two decades of experience and a reputation for enhancing efficiency and accuracy, Imagenet partners with health plans to streamline processes and improve member satisfaction. Their services are designed to reduce claims turnaround times, increase processing capacities, and lower contact center wait times. By integrating scalable solutions tailored to specific needs, Imagenet enables healthcare organizations to accelerate productivity and mitigate operational challenges.

📋 Description

• Review and adjudicate medical claims, ensuring accurate coding, data entry, and application of reimbursement methodologies • Process professional, institutional, adjusted, corrected, and other complex claim types • Review and investigate provider dispute requests, appeals, reconsiderations, and claim adjustments • Verify member eligibility, provider participation, benefit coverage, and supporting documentation • Research claim discrepancies and determine outcomes based on contracts, benefits, policies, and regulations • Request additional information and collaborate with internal stakeholders to resolve claim issues • Process claims from initial review through final adjudication and document decisions and actions • Handle complex claims involving multiple services, providers, benefits, or reimbursement methodologies • Identify and escalate unusual or high-risk claims requiring additional review • Maintain detailed and accurate claims-processing records • Meet established productivity, quality, and timeliness standards • Participate in training, calibration sessions, and professional development initiatives • Work independently with limited supervision while adapting to evolving procedures and claim scenarios

🎯 Requirements

• Minimum 3 years of healthcare claims adjudication experience, preferably within a managed care, health plan, TPA, or payer environment • Experience processing medical claims from initial review through final adjudication • Strong understanding of healthcare claims processing and reimbursement principles • Ability to research, analyze, and resolve claim discrepancies and exceptions • Strong attention to detail and sound decision-making skills • Ability to manage workload effectively and meet productivity expectations • Effective written and verbal communication skills • Ability to work independently and collaboratively within a team environment • Basic to intermediate Microsoft Office skills • Ability to perform basic mathematical calculations and verify claim accuracy • Preferred: Experience processing Provider Dispute Resolution (PDR), appeals, reconsiderations, and claim adjustments • Preferred: Managed care or health plan claims processing experience • Preferred: Experience processing multiple claim types and lines of business • Preferred: Knowledge of medical terminology • Preferred: Understanding of ICD-10, CPT, and HCPCS coding • Preferred: Experience handling complex claims requiring research, interpretation, and independent judgment

🏖️ Benefits

• Ongoing professional development initiatives • Training and calibration sessions • Continuous learning and professional growth opportunities • Fully remote work setup