Imagine360

Role Description Imagine360 is seeking a Provider Data Management Specialist to join the team! The Provider Data Management Specialist is responsible for installation and ongoing maintenance of contracted provider data. This directly impacts the experience of the members, providers, and third-party administrators that access contracted providers and utilize provider look-up data. Position Location: 100% remote - Set up and load systems with new provider demographic information once contract is executed with the provider. - Experience using SQL and data analytic tools for reporting and data analysis. - Ensure the data loads meet quality standards. - Participate in testing and audit activities related to data integrity and accuracy. - Monitor and update data based on revised rosters received from health systems and other contracted providers in a timely manner. - Ensure organized storage of all relevant provider documents. - Investigates and resolves provider file inaccuracies and discrepancies, coordinating with other departments as necessary. - Interact with provider offices to verify updates to provider information. - Assist with provider education efforts on contracted status inquiries. - Support provider contracting department with issue resolution and data needs as appropriate. - Coordinate with Credentialing department to identify and update provider data based on provider credentialing efforts. - Understanding department, segment, and organizational strategy and operating objectives, including their linkages to related areas. - Provide feedback on system limitations or expansion needs as a user of provider management database. - Participate in any testing and validation of system changes and improvements. - Other duties as assigned. Qualifications - Associate Degree or relevant experience. - Previous provider data loading and maintenance. - Previous health insurance/network experience. Requirements - Proficient in the MS Office Suite to include MS Word, Excel, and Outlook. - Excellent organizational, interpersonal, presentation, facilitation, and communication skills. - Demonstrated commitment to high professional ethical standards. - Ability to adapt to a fast-paced, continually changing business and work environment while managing multiple priorities. - Excellent follow-through skills, self-motivated and detail-oriented. - Strong organizational skills to manage multiple projects, issues, and priorities effectively and simultaneously, with attention to detail. 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.

Role Description Imagine360 is seeking a Plan Document Technician to join the team! The Plan Document Technology and Workflow Specialist is responsible for designing, building, maintaining, and improving scalable SharePoint sites, internal tools, trackers, workflows, and system-support processes used by the Plan Documents department. This position supports the technical infrastructure behind the department's work by helping ensure that tools, sites, workflows, and system enhancements remain efficient, sustainable, accurate, and responsive to changing business needs. The role also supports system enhancement efforts, and partners with department leadership and internal stakeholders to translate operational needs into practical, well-organized technical solutions. Position Location: 100% remote Duties/Responsibilities - Designs, builds, organizes, and maintains scalable SharePoint sites, libraries, pages, lists, and related internal tools that support Plan Documents workflows, resources, communication, and document management needs. - Create sustainable technical solutions that support day-to-day operations. - Maintains the technical infrastructure supporting Plan Documents work, including SharePoint structures, workflow logic, tracker integrity, access considerations, naming conventions, version control, and process documentation. - Builds and updates internal tools, templates, lists, forms, dashboards, or other department resources to improve consistency, efficiency, tracking, and accountability across Plan Documents functions. - Reviews existing tools and workflows on an ongoing basis to identify opportunities for improvement, simplification, automation, consolidation, or retirement of outdated resources. - Assists with user testing, troubleshooting, and enhancement validation to ensure new or modified tools function as intended and align with operational requirements. - Develops and maintains clear instructions, job aids, workflow documentation, and training materials for tools and processes supported by this position. - Coordinates with internal stakeholders, including Legal, Operations, IT, Implementation, and other departments, as needed to support cross-functional process alignment and system usability. - Helps ensure department tools and workflows are structured in a way that supports accuracy, continuity, scalability, auditability, and long-term sustainability. - Performs other related duties as assigned based on department needs and business priorities. Qualifications - High School Diploma or GED (Required). - Associate's or Bachelor's degree in Business Administration, Information Systems, Health Administration, Project Management, or a related field; or equivalent combination of education and relevant experience (Preferred). - 3+ years of experience supporting business operations, document management, workflow coordination, SharePoint sites, internal tracking tools, systems, or process improvement (Required). - Experience working with Microsoft Office products and maintaining organized electronic records, trackers, or departmental resources (Required). - Experience designing or administering SharePoint sites or lists; experience with workflow tools, business process documentation, system testing, reporting, automation (Preferred). Skills and Abilities - Working knowledge of Microsoft Office products, SharePoint, Teams, Excel, and related Microsoft 365 tools. - Ability to design organized, scalable internal sites, trackers, lists, workflows, and resource structures that are easy for business users to navigate and maintain. - Strong attention to detail, accuracy, consistency, formatting, naming conventions, and process documentation. - Ability to evaluate existing workflows and recommend practical improvements that reduce rework, improve visibility, and support sustainable operations. - Ability to translate business needs into functional technical requirements, tool layouts, tracker fields, workflow steps, and user-friendly instructions. - Strong problem-solving skills, including the ability to troubleshoot issues, test enhancements, document findings, and follow through to resolution. - Ability to manage multiple priorities, changing requirements, and time-sensitive requests while maintaining professionalism and accuracy. - Strong written and verbal communication skills, including the ability to explain technical concepts in clear, practical, business-friendly language. - Ability to work independently while collaborating effectively with department leadership, peers, IT, operations, and other internal stakeholders. - Commitment to maintaining efficient, sustainable, and well-documented tools and processes that support the Plan Documents department. Licenses or Certification - None required. - SharePoint, Microsoft 365, Power Platform, Power Automate Flows, Copilot Agents, project management, or related technology/process certifications preferred. 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

Role Description Imagine360 is currently seeking an Analyst I to join our team! The Analyst I is an entry-level position responsible for collecting, analyzing, and interpreting data to support decision-making processes within the organization. This role involves using statistical techniques and data visualization tools to provide actionable insights that drive business strategies and improvements. Position Location: 100% remote Responsibilities include but are not limited to: - Data Collection and Management: - Retrieve and compile data from various sources such as databases, spreadsheets, and external data sources. - Ensure the accuracy, consistency, and reliability of data through routine checks and validation. - Data Analysis: - Perform basic statistical analysis to identify trends, patterns, and correlations in data. - Assist in the development and maintenance of reports and dashboards that track key performance indicators (KPIs) and other metrics. - Reporting and Visualization: - Create and present data visualizations, including charts, graphs, and tables, to effectively communicate findings. - Prepare ad-hoc reports and presentations to support various business units and projects. - Data Quality and Improvement: - Conduct routine data quality assessments to identify and resolve data issues. - Contribute to the development of processes and procedures to improve data collection, analysis, and reporting. - Collaboration: - Work closely with team members and stakeholders to understand their data needs and provide analytical support. - Participate in meetings and discussions to provide insights and recommendations based on data analysis. Qualifications - Bachelor's degree in a relevant field required (e.g., statistics, mathematics, computer science, healthcare management). Requirements - Proficiency in Excel and statistical software (e.g., R, Python). - Strong analytical and problem-solving skills. - Team experience working closely with business professionals and technical resources to act as a bridge between the two groups (internal / external). - Basic understanding of healthcare data sources and terminology preferred. - Artificial intelligence experience preferred. - Excellent organizational skills, with acute attention to detail. Benefits - Multiple Health Plan Options, including a 100% employer paid premiums option. - 100% 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.

Role Description Imagine360 is seeking a Senior Operations Specialist to join the team! We are looking for an experienced operations professional with deep expertise in EDI (Electronic Data Interchange), specifically HIPAA 834 Enrollment and 837 Claims transactions, to lead implementation efforts and provide strategic operational support for third-party administrator (TPA) partnerships. This role serves as the operational lead for new TPA onboarding, overseeing implementation projects from planning through production while ensuring seamless integration, testing, and long-term operational success. The Senior Operations Specialist will act as the primary operational liaison for TPAs, lead cross-functional initiatives, identify process improvements, and provide subject matter expertise on EDI transaction workflows. Position Location: 100% remote Responsibilities include but are not limited to: - EDI Implementation Support: - Lead end-to-end operational onboarding of new TPAs, managing implementation timelines, deliverables, risks, and cross-functional coordination. - Serve as the operational project manager for EDI implementations involving 834 Enrollment and 837 Claims transactions. - Lead technical and operational meetings with TPAs and internal stakeholders throughout implementation. - Oversee testing and validation of inbound and outbound EDI files to ensure compliance with HIPAA standards, partner specifications, and business requirements. - Coordinate implementation activities across Operations, IT, Finance, Claims Audit, Client Implementations, Client Experience, and Member Services to ensure successful go-live. - Identify implementation risks, proactively develop mitigation strategies, and drive timely resolution of issues. - Production Support & Operational Oversight: - Serve as the primary operational owner for assigned TPA relationships following implementation. - Monitor production performance and proactively identify opportunities to improve transaction quality, turnaround times, and operational efficiency. - Investigate and resolve complex production issues involving claims routing, enrollment, file processing, and eligibility discrepancies. - Lead root cause analysis for recurring issues and partner with technical and business teams to implement long-term corrective actions. - Track operational metrics, partner performance, and implementation outcomes, providing recommendations for continuous improvement. - Cross-Functional Collaboration: - Serve as the subject matter expert for 834 and 837 transaction workflows and related operational processes. - Partner with Finance, Claims Audit, IT, Client Implementations, Client Experience, and Member Services to resolve complex operational challenges. - Provide guidance and operational expertise during new client and partner implementations. - Facilitate communication across departments to ensure alignment on project priorities, issue resolution, and service delivery expectations. - Mentor team members by sharing best practices and supporting knowledge transfer related to EDI operations and TPA management. - Process Documentation & SOP Development: - Develop, maintain, and enhance SOPs, implementation playbooks, and operational documentation. - Identify opportunities to improve workflows, increase automation, and standardize operational processes. - Recommend enhancements to existing implementation methodologies based on lessons learned and industry best practices. - Ensure documentation remains current, scalable, and accessible across teams. - Partner Relationship Management: - Build and maintain strong operational relationships with third-party administrators. - Lead recurring operational business reviews with TPAs to discuss implementation status, production performance, claims aging, open issues, and service improvements. - Serve as the escalation point for complex operational concerns requiring cross-functional coordination. - Maintain detailed implementation documentation, issue logs, and action plans through project completion. Qualifications - Required: - Bachelor's degree or equivalent combination of education and experience. - 3-5+ years of experience supporting healthcare EDI operations with significant hands-on experience managing HIPAA 834 Enrollment and 837 Claims transactions. - Demonstrated experience leading or project managing EDI implementations and onboarding new TPAs or healthcare trading partners. - Strong understanding of healthcare claims processing, eligibility and enrollment workflows, and TPA operations. - Proven ability to independently manage multiple implementation projects and competing priorities in a fast-paced environment. - Excellent project management, communication, organizational, analytical, and problem-solving skills. - Experience collaborating across technical and business teams to drive successful implementation outcomes. - Preferred: - Experience working with healthcare clearinghouses, EDI mapping tools, or healthcare integration platforms. - Knowledge of payer systems, claims adjudication processes, and healthcare interoperability standards. - Experience developing SOPs, implementation documentation, and operational playbooks. - Experience analyzing operational metrics and producing performance reporting. - Previous experience mentoring team members or serving as a functional subject matter expert. Skills and Abilities - SQL and Excel 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

Role Description Imagine360 is seeking a Manager, Care Advocacy, to join the team! The Manager drives robust strategies to ensure an elevated member experience. Responsibilities include but are not limited to: - Partner with the Member Care Advocacy Director to develop contact center strategies through the assessment of team needs, performance metrics, proactive assessment of processes, driving accountability with a focus on performance-based rewards. - Promote, support and drive a dynamic teamwork environment that fosters positive morale, unity, cohesiveness, effective communication and service excellence. - Leverage subject matter expertise to oversee and provide counsel on elevated issue resolution. - Contribute expert analysis as required for the strategic plans of the organization. - Maintain contact center KPIs while seeking opportunities to advance operations through monitoring system performance, identifying and resolving problems, and driving quality improvement. - Accomplish team related human capital objectives through involvement in recruiting, selecting, assigning, coaching, counseling, disciplining, and educating employees. - Communicate individual and team job expectations while motivating staff to accomplish goals and reach their full career potential. - Coordinate, review and oversee individual goals, annual reviews and HR issues. - Collaborate with leadership and analytics team to collect, analyze, and draw conclusions about team and individual performance, identify and leverage trends to create proactive solutions. - Analyze reports to assess, measure and monitor productivity, quality and related trends. - Work closely with Quality Assurance team to assess individual and team performance and associated trends that may correlate to additional training needs or necessary process efficiencies. - Conduct real-time and as-needed training/coaching/development meetings. - Conduct 1-on-1 meetings with team members to encourage employee engagement and open lines of communication. Qualifications - Bachelor's degree or equivalent combination of some college and demonstrated work experience. - Proven leadership experience in a service environment, preferably a contact center. - Proven staff development experience in coaching, mentoring, performance management, career pathing, goal-setting and effective motivational and teambuilding expertise. Requirements - Healthcare Benefits/Insurance industry experience a strong plus. - Ability to implement solutions with little supervision in a fast-paced environment and provide supervision and mentorship to their team. - Strong technology skills (Microsoft products). - Superior, established problem-solving skills. - Exhibit a strong passion for service, developing employees, mentoring/coaching and motivating others to succeed. - Excellent verbal and written communication skills with the ability to resonate with others to impact positive outcomes. - Team player, able to collaborate with others. 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.

Role Description Imagine360 is seeking a Claims Internal Auditor to join the team! This position uses a systematic, disciplined approach to review and evaluate the effectiveness and efficiency of operations, processes, controls, and practices, as well as related procedures, according to the approved audit plan. Position Location: 100% remote - Develops the scope for operational, implementation, renewal, and internal controls audits, selecting/developing appropriate audit steps necessary to promote effective audit coverage. - Responsible for reviewing and assessing processes, controls, practices, and related procedures according to approved audit plans for selected areas of the organization to ensure legal compliance and consistency of internal controls. - Proposes value-added recommendations to improve the effectiveness and efficiency of operational and management processes and system controls. - Collects and analyzes results of audits to identify discrepancies between work processes and documented standards, deficient controls, root causes of non-conformance, or non-compliance with laws, regulations, or plan documents. - Conducts ad-hoc investigations and reviews as requested by management. - Coordinates with external and client auditors to ensure data and information is provided to and received from auditors and auditing entities; provides timely response to audit reports and completes overviews for management review. - Maintains integrity of data within Internal Audit database; develops and runs a variety of database reports for internal and external reporting requirements, and ad hoc reports as requested. Qualifications - High School Diploma or GED required. - Two-year associates degree preferred. - 2+ years of claims, eligibility or related industry work experience required. Skills and Abilities - Proficient use of computers and software including but not limited to Microsoft Office products. - Strong written, oral communication and presentation skills including the ability to explain audit findings and to influence others to implement audit recommendations. 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 Description 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.

Role Description Imagine360 is seeking a Supervisor, Clinical Intake to join the team! The Supervisor, Clinical Intake is responsible for leading a team by providing oversight and guidance on Medical Management non-clinical tasks, processes, and operations. The Supervisor is also responsible for supporting projects across the team and department and additional tasks as needed. Position Location: 100% remote Responsibilities include but are not limited to: - Supervisory Responsibilities: Medical Intake Specialists - Responsible for the day-to-day management, oversight, and guidance for the Medical Intake team and their associated tasks; works with employees to problem solve and make operational processes most efficient. - Responsible for the call queue and appropriate staffing to maintain abandonment rate < 3%. - Responsible for the performance management and corrective action process for all team members in partnership with the Senior Manager. - Perform monthly 1:1 coaching with each MIS staff for quality improvement and metrics. - Perform monthly call and chart audit for the MIS staff and reports to UM Manager/Senior Manager. - Review QA results to develop educational opportunities for the MIS staff and completes performance improvement plans for scores < 90% per policies and procedures. - Review and manage approvals and communications for PTO requests by employees, as directed by the Manager or Senior Manager. - Develop training, maintain training materials, and facilitate training for existing and new team members. - Lead the interviewing and hiring processes as needed with UM Supervisor or Manager. - Act as role model within a team setting to provide mentoring, coaching, and positive outcomes for employees, peers, and overall operations. - Appropriately escalates difficult issues as needed. - Develop daily workflow processes and procedures, as well as develop and implement non-clinical policies and procedures. - Support the process to appropriately distribute and prioritize calls received in the telephonic intake queue for the team. - Refer to licensed clinical staff for oversight/review of clinical information as instructed. - Create and distribute reports for the department and team as needed by internal or external requests for data. - Based on high volumes, will manage or delegate daily medical intake tasks and calls. - Will create and assign program-specific tasks following approved criteria for task assignments. - Accurately identify and provide HIPAA compliant information to callers regarding medical services requiring notification per Medical Management Notification Policy and Procedures. - Complete data entry of notification and obtain clinical information and/or results of diagnostic testing as indicated per the Medical Management Notification Policy and Procedure in times of high case/call volume. - Contact provider/facility to confirm the date of service, as indicated per Medical Management Notification Policy & Procedure, with appropriate documentation in case tracking software in compliance with Medical Management Policies and Procedures. - Consistently complete appropriate documentation in software including but not limited to CaseTrakker, GBAS and Docushare per Medical Management Policy and Procedures. - Consistently demonstrate engagement in professional conversation in all internal and external communications (verbal and/or electronic). - Participate in Medical Management quality programs, as well as provide support and project coordination for Medical Management quality initiatives as needed. - Lead bi-monthly meetings for MIS team, will participate in department wide meetings and trainings or other job specific events as required by teleconference or onsite. - Work collaboratively and cross functionally across the Medical Management department. - Submit IT tickets on system issues as needed for the team. - Communicate proactively and effectively with internal or external peers and leadership. - Support other tasks and projects as needed across the department, on time and accurately. - Perform all tasks in accordance with HIPAA/PHI guidelines. - Adhere to established internal regulations regarding Department of Labor, HIPAA, ERISA and department and company policies and procedures. - Complete HIPAA training and Trainings assigned by quality team monthly/annually. Qualifications - Required Education: High school degree or equivalent experience. - Preferred Education: Bachelor's degree preferred but not required. - Required Experience: 3 years' experience in an administrative or operational role. - Proven success in managing tasks accurately and on time. - Experience maintaining a high level of accuracy and attention to detail to perform each essential duty satisfactorily. - Advance knowledge and skills using Microsoft Office including Word, Excel, and PowerPoint software; Internet software; Database software. - Preferred Experience: Prior experience leading a team and managing direct reports. - Success at leading process improvement initiatives. - Administrative and operational experience within the healthcare industry preferred. Skills and Abilities - Ability to read and interpret documents such as HIPAA compliance, safety rules, operating and maintenance instructions, and policy and procedure manuals. - Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. - Ability to deal with problems and exercise sound judgment involving several concrete variables in standardized situations. - Ability to resolve problems independently and demonstrate ability to multi-task. - Strong verbal and written communication skills. - Strong presentation skills. - Ability to demonstrate a commitment to building new skills and fostering a positive work environment within a team setting. 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 Description 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.

Role Description Imagine360 is seeking a Disease Management Care Coach, Cardiology to join the team! The Care Coach is responsible for providing telephonic coaching and educational resources to people with chronic health conditions. Coaching topics include medication compliance, nutrition, physical activity, and care coordination. Responsibilities include assessment, coordination, planning, monitoring, and evaluation. Position Location: 100% remote Responsibilities include but are not limited to: - Provide telephonic coaching, and information and referral services to program participants managing various chronic health conditions with clinical oversight assistance. - Assess participant needs using scripted assessments. - Communicate, as needed, with service delivery partners, physicians, and other health professionals to provide care coordination. - Review pertinent medical history, current diagnosis, and pharmaceutical data via information database system with clinical oversight. - Assist participant in forming realistic goals related to overall health. - Determine and provide relevant community and/or healthcare resources that help support participant's goals. - Promote wellness and provide education regarding preventative care measures. - Effectively assess, coach and graduate clients from care, resulting in appropriately managed caseloads. - Document participant activities and coaching/counseling sessions in established format in the case tracking software. In addition to performing standard Care Coach roles, Registered Nurses are involved in clinical decision-making and patient education. The scope of practice for nursing work includes, but is not limited to: - Rationale for the effects of medications and treatments. - Implement measures to promote a safe environment for clients and others. - Accurately report: - Administration of medication and treatments. - Client response. - Contact with other health care team members. - The client's status including signs and symptoms. - Nursing care (education) rendered. - Respect the client's right to privacy by protecting confidential information. - Promote and participate in education and counseling to a participant based on health needs. - Clarify any treatment that is believed to be inaccurate, non-efficacious, or contraindicated by consulting with appropriate practitioner. - Know, recognize, and maintain professional boundaries of the nurse-client relationship. Qualifications - Nursing Degree from an accredited college or university. - 2+ years of experience in direct participant coaching. Requirements - Must have intermediate knowledge and skills using Microsoft Office including Word, Excel, and PowerPoint software; Internet software; Database software. - Active and unrestricted Compact Registered Nurse License required. 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.

Role Description Imagine360 is seeking a Utilization Management, RN to join the team! The RN Utilization Management Nurse is responsible for providing utilization review/notifications and education for individuals under the group health plans administered by Imagine360 by utilizing nursing education, clinical, and professional experience. The Registered Nurse will practice within the scope of practice while performing assessments, coordination, planning, monitoring, and evaluation. Position Location: 100% remote - Perform all tasks in accordance with Department of Labor, HIPAA, ERISA and Care 360 department Policy and Procedures. - Complete HIPAA and URAC training annually. - Identify, collect, process and manage data to complete reviews for Medical Necessity per Imagine360 approved clinical guidelines. - Accurate utilization and documentation in appropriate software including time slips in CaseTrakker to complete and document the review process per Care 360 Policy and Procedure. - Provide oversight to non-clinical staff members regarding interpretation of clinical data. - Consult with Care 360 Physician Advisor or peer reviewer per policy and procedures. - Assess and review current treatment history to identify appropriate referrals to Case Management Program or other Care 360 Services. - Communicate professionally and effectively as needed with members, physicians, other healthcare professionals, peers, Supervisor of UM to complete the utilization process per Care 360 Policy and Procedures. - Utilize clinical knowledge, expertise and Imagine360 approved educational resources to provide verbal and/or written educational resources to members regarding diagnosis, procedures and/or treatment. - Attend scheduled and periodic meetings, training and other job specific events as required either by teleconference or onsite. - Participate in the Quality Management program of the organization by completing the Quality Assurance review process and other procedures per policy and procedure. - Work regular scheduled hours and be available for additional coverage outside of normal working hours as needed. - Evaluate clinical data. - Assess and evaluate the acquired clinical data to assess for appropriateness of treatment plan based upon Imagine360 clinical guidelines. - Coordinate treatment plans, interventions and outcomes measurement. - Provide rationale for the effects of medication and treatments. - Provide patient education and educational resources. - Accurately report: Administration of medication and treatments, Client response, Contact with other health care team members. - Respect the client's right to privacy by protecting confidential information. - Promote and participate in education and counseling to a participant based on health needs. - Clarify any treatment that is believed to be inaccurate, non-efficacious, or contraindicated by consulting with appropriate practitioner. - Other duties as assigned. Qualifications - Nursing Degree from an accredited college or university and an active, current, and unrestricted Registered Nurse License in eNLC compact state. - Bachelor's degree preferred. - 1+ year in Utilization Management and/or Case Management experience. - Experience in utilization review services preferred. - Experience and knowledge of CPT and ICD coding preferred. Requirements - Ability to read and interpret documents such as HIPAA compliance, safety rules, operating and maintenance instructions, and policy and procedure manuals. - Ability to write routine reports and correspondence. - Ability to speak effectively to members and employees. - Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, and percentages. - Ability to apply concepts of basic mathematics and fundamental accounting principles. - Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. - Ability to deal with problems and exercise sound judgment involving several concrete variables in standardized situations. - Basic knowledge and skills using Microsoft Office Word, Internet software, and Database software. License and Certifications - Current, active, and unrestricted compact Registered Nurse license. Must maintain CEUs as required by the State Board of Nursing. - Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization. - Current Certified Case Manager (CCM) Certificate preferred; if Certification is not current, employee must pursue and achieve CCM Certification within three years of employment. 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.

Role Description Imagine360 is seeking an Oncology Case Manager RN to join the team! This RN provides excellence in care through empowering patients, maintaining open communication, coordinating sequence of care, aiding in avoidance of complications, arranging alternative facilities, coordinating appropriate treatment with cost containment strategies, educating and supporting not only the member but the support systems. The Oncology Case Manager RN facilitates coordination of both inpatient and outpatient patients with active oncology diagnoses or in the family of diagnoses. Position Location: 100% remote Position Start Date: 9/21/26 Responsibilities include but are not limited to: - Identify, collect, process, and manage data to perform the Case Management process by utilization of Imagine360 approved clinical guidelines and following Medical Management Policy and Procedures. - Completes clinical assessments per P&P to identify and deliver indicated medical service coordination. - Manage the transplant cases, cases that may lead toward organ transplant, and complex disease cases. - Utilize clinical knowledge, expertise, and educational resources to provide verbal and/or written educational resources to members regarding diagnosis, procedures and/or treatment. - Assess the need for and collaborate with community resources for members in case management. - Uses assigned software accurately to document all steps of review of medical necessity and case management process, including time slips. - Facilitate the Patient Satisfaction Surveys. - Assess for cost savings and document the cost saving in assigned software. - Appropriately refer complex cases to Supervisor, Case Management, or designee. - Performs essential activities of case management while maintaining members' confidentiality, safety, advocacy, adherence to ethical, legal and accreditation and regulatory standards. - Performs assessments of each member to identify CM needs. - Consistently exercises discretion and judgment to analyze, interpret, make deductions, and then decide what actions are necessary based on the varying facts and circumstances of each individual case. - Determines measurable goals utilizing motivational interviewing and behavior change model and coaches' clients while monitoring self-care practices. - Utilizes industry standard tools to guide individuals with chronic/ongoing health conditions through coaching, assessments, listening, and other techniques as appropriate. - Executes activities or interventions to achieve the goals in the plan. - Organizes, integrates, and modifies the resources needed to reach the goals in the plan. - Monitors all information from all relevant sources in the plan and its activities and services to determine the plan's effectiveness. - At repeated intervals, evaluates to determine ultimate effectiveness of plan and modifies plan appropriately to meet the goals. - Research medical procedures, treatments, and coding when necessary. - Measures the outcomes of interventions. - Adheres to practicing the care management core components throughout the continuum of care: - Case Management Concepts - Case Management Principles and Strategies - Psychosocial and Support Systems - Healthcare Management and Delivery - Healthcare Reimbursement - Vocational Concepts and Strategies - 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. - Appropriately escalates difficult issues up the chain of command. - 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 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. - Develop new or improve current internal processes to improve quality. - Attend and participate in team meetings, trainings, and other job specific events as required. - Communicates (in compliance with HIPAA) with brokers, vendors, Relationship Managers, HR representatives and stop loss as needed. - Communicates professionally and effectively. - Adhere to established internal regulations regarding Department of Labor, HIPAA, ERISA and department and company policies and Procedures. - Participate in the Quality Management Program via collecting and adhering to performance metrics per Case Management Policy. - Complete HIPAA Training Annually. - Perform all tasks in accordance with HIPAA/PHI guidelines. - Appropriately escalate difficult issues. - Complete duties in accordance with scope of licensure and certifications held or requested. - Perform other duties and projects, as assigned. Qualifications - A nursing degree from an accredited college, university, or school of nursing. - Minimum of two years in Oncology experience required. - Minimum of one year experience in Utilization Management, Case Management, or transferable skills. Requirements - Ability to work independently in a home office environment. - Computer skills which include proficiency in Microsoft Outlook, Word, Excel, and PowerPoint, as well as navigation utilizing the internet. - Ability to resolve problems independently and demonstrate ability to multi-task. - Strong written, oral, and telephonic communication skills. - Strong presentation skills. - Ability to demonstrate a commitment to building new skills and fostering a positive work environment. - Demonstrated organizational skills, problem-solving, analytical skills, and detail oriented. - Demonstrated ability to prioritize workloads, multi-task, and manage priorities to meet deadlines. - Ability to maintain the confidentiality of protected health information in compliance with HIPAA regulations. License and Certifications - Current, active, and unrestricted compact Registered Nurse license. Must maintain CEUs as required by the State Board of Nursing. - Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization. - Must be a Certified Case Manager or eligible to sit for the Certified Case Management Exam within 3 years of starting employment with i360. 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.