Note: The job is a remote job and is open to candidates in USA. Imagine360 is a health plan solution company that combines over 50 years of self-funding healthcare expertise. They are seeking an Operations Specialist to support EDI implementations and post-implementation production support, focusing on 834 Enrollment and 837 Claims transactions with third-party administrators. The role involves collaborating across departments to resolve issues and improve processes while acting as the main point of contact for TPAs.
Responsibilities
- Participate in and support technical calls related to EDI implementation efforts
- Assist in testing of 837 outbound files with TPAs to ensure compliance with specifications and claims processing requirements
- Track, manage, and report on implementation milestones and deliverables
- Collaborate closely with internal stakeholders to ensure timely and accurate file exchange setup and validation
- Serve as the primary operational contact for TPAs post-implementation
- Monitor and resolve production issues, including claims routing, file errors, and processing discrepancies
- Triage and resolve inquiries related to aging claims, inventory backlogs, and escalated partner concerns
- Escalate and track systemic issues for resolution with the appropriate technical or business teams
- Work collaboratively with Finance, Claims Audit, IT, Client Implementations, Client Experience, and Member Services teams to support issue resolution across claim, enrollment, and eligibility processes
- Provide updates and operational insights into partner performance and transaction health
- Coordinate root cause analysis and implement corrective actions as needed
- Ensure partner needs are reflected in service delivery and internal processes
- Develop and maintain detailed SOPs for new EDI implementations and ongoing operational tasks
- Identify opportunities for operational process improvements and automation
- Ensure all documentation is updated and accessible for relevant teams
- Act as the main operational liaison to third-party administrators
- Conduct and lead monthly operational check-ins with partners to review claims aging, performance metrics, and open items
- Maintain detailed documentation of partner communications, tracking issues to resolution
Skills
- Bachelor's Degree or 1+ years of experience in EDI operations or healthcare data exchange, with hands-on exposure to 834/837 HIPAA transaction sets
- Strong understanding of healthcare claims processing, eligibility/enrollment workflows, and TPA coordination
- Demonstrated ability to work cross-functionally in a fast-paced environment
- Excellent communication, analytical, and problem-solving skills
- Proven ability to handle multiple competing priorities with attention to detail
- Experience with clearinghouses, EDI mapping tools, or healthcare integration platforms
- Familiarity with payer systems, claims adjudication processes, or TPA operations
- Background in writing SOPs or internal process documentation
- Previous analytics and reporting skills a plus
Benefits
- 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
Company Overview
Imagine360 is an integrated health plan addressing one of the greatest challenges on behalf of self-funded employers: healthcare costs are harming the bottom line, they're increasingly unaffordable for employees, and the experience remains poor. It was founded in 2003, and is headquartered in Philadelphia, Pennsylvania, USA, with a workforce of 1001-5000 employees. Its website is https://mibenefits.imagine360.com.