About The Company
Imagenet is a leading provider of back-office support technology and tech-enabled outsourced services to healthcare plans nationwide. The company specializes in claims processing services, including digital transformation, claims adjudication, and member and provider engagement solutions. As a mission-critical partner, Imagenet enhances engagement and satisfaction for healthcare plans' members and providers by delivering reliable and efficient services. Currently serving over 70 health plans, Imagenet processes millions of claims annually, managing complex data elements with precision. The company has developed innovative workflow technology, JetStreamTM, which facilitates traceability, governance, and automation of claims operations, ensuring high standards of accuracy and compliance. Headquartered in Tampa, Florida, Imagenet operates 10 regional offices across the United States and maintains a wholly owned global delivery center in the Philippines, supporting its extensive operational footprint and commitment to excellence.
About The Role
The Claims Quality Analyst is a vital role within the organization, responsible for ensuring the accuracy, compliance, and overall quality of claims processing and provider dispute resolution. This remote position reports directly to the Claims Supervisor and requires a candidate with hands-on experience in healthcare claims, particularly with EZCap, and familiarity with Medi-Cal and commercial health plans. The primary focus of this role is to perform detailed audits of denied, underpaid, and processed claims to verify accuracy and adherence to provider contracts and regulatory guidelines. The analyst will analyze provider disputes to identify recurring issues and root causes, collaborating with cross-functional teams to implement corrective actions and process improvements. Additionally, the Claims Quality Analyst will develop performance metrics related to claims accuracy, turnaround times, and dispute resolution efficiency. The role also involves supporting training initiatives by identifying knowledge gaps and assisting in the development of updated procedures based on audit findings. Ensuring compliance with applicable regulatory requirements, participating in audits, and contributing to continuous operational improvements are key responsibilities of this position.
Qualifications
- High school diploma or equivalent
- At least 3-5 years of experience as a Quality Analyst in healthcare, TPA, or health plan settings, specifically in healthcare claims or claims processing/adjudication environments
- Hands-on experience with EZCap (strongly preferred)
- Familiarity with Medi-Cal and Commercial insurance claims
- Strong analytical and problem-solving skills
- Excellent verbal and written communication abilities
- Attention to detail in documentation and compliance
- Ability to manage multiple tasks and meet deadlines effectively
- Experience with other claim adjudication platforms and provider systems
- Knowledge of DHCS, DMHC, and CMS dispute handling regulations
Responsibilities
- Perform detailed audits of denied, underpaid, and processed claims using EZCap to ensure accuracy and regulatory compliance
- Analyze provider disputes to identify patterns, recurring issues, and root causes
- Collaborate with relevant teams to develop and implement corrective actions and process improvements
- Develop and monitor performance metrics related to claims accuracy, processing turnaround times, and dispute resolution efficiency
- Conduct root cause analyses on high-impact errors or escalations to prevent future issues
- Support training initiatives by identifying knowledge gaps and updating procedures and documentation based on audit findings
- Ensure all processes reviewed are compliant with applicable regulatory standards
- Participate in internal and external audits as required
- Contribute to continuous improvement efforts within claims processing workflows
Benefits
- Remote work flexibility
- Equipment provided to facilitate work from home
- Paid comprehensive training programs
- Medical, Dental, and Vision insurance coverage
- Life insurance and Health Savings Account (HSA)
- 401(k) retirement plan with company contributions
- Paid Time Off (PTO) and 7 paid holidays annually
- Supportive team environment with opportunities for internal growth
Equal Opportunity
Imagenet is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.