Imagine360 is currently seeking a Manager, Medical Claims to join the team! The Manager, Medical Claims, is responsible for leading the end‑to‑end process of preparing, validating, and submitting stop‑loss claims to ensure timely and accurate reimbursement for high‑cost medical claims. This role oversees daily team operations, establishes workflow and quality standards, and collaborates with internal and external parties to resolve issues and optimize outcomes. The manager drives continuous improvement, ensures compliance with contractual and regulatory requirements, and provides strategic oversight to support financial recovery and operational excellence. Position Location: 100% Remote Supervisory Responsibilities: - Stop Loss Filing Team - Stop Loss Filing Team Supervisors Leadership - Lead, coach, and develop a team of Stop Loss Filing Specialists and Analysts. - Oversee day‑to‑day workflow management, ensuring timely assignment, processing, and submission of all stop loss claims. - Establish performance standards, quality controls, and productivity expectations. - Provide ongoing training to ensure staff expertise in stop‑loss processes, coordination of benefits (COB), and claim documentation requirements. Stop Loss Claims Management: - Manage the complete lifecycle of specific and aggregate stop‑loss filings, including claim preparation, eligibility verification, documentation assembly, and carrier submission. - Audit claims against plan document, stop loss contract, and carrier standards - Facilitate financing of approved claims with finance - Pend claims and issue denials to third party administrator where appropriate - Elevate complex claim issues for clinician or management review Claims Support: - Compile periodic reporting for internal and external parties - Advise on claim projections and development Quality Assurance: - Develop and maintain standardized filing procedures, policies, and best practices. - Performs self-quality monitoring to develop and execute plans to meet established goals - Identify process gaps and lead continuous improvement initiatives to increase accuracy, speed, and reimbursement rates. - Collaborate with peers and cross-departmentally to improve or streamline procedures Education: - High School Diploma or GED. - Associate degree in Business Administration, Healthcare Administration, Finance, or a related field. - An equivalent combination of education and relevant stop‑loss or claims experience may be considered in place of a degree, depending on organizational policy. Experience: - 2-3 years of team leadership or supervisory experience. - Excellent analytical skills, attention to detail, and problem‑solving ability. - Strong communication skills with experience managing external partner relationships. - 8+ years of experience in stop loss insurance, medical claims, health plan operations, or related field. What can Imagine360 offer you? - Multiple Health Plan Options, including a 100% Employer Paid Benefit Options - 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 Want to see our latest job opportunities? Follow us on LinkedIn 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**

• Analyzes and processes complex or technically difficult general liability claims by investigating and gathering information to determine the exposure on the claim. • Manages claims through well-developed action plans to an appropriate and timely resolution. • Assesses liability and resolves claims within evaluation. • Negotiates settlement of claims within designated authority. • Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim. • Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles claims within designated authority level. • Prepares necessary state fillings within statutory limits. • Manages the litigation process; ensures timely and cost effective claims resolution.

• Analyze mid- and higher-level general liability claims to determine benefits due • Ensure ongoing adjudication of claims within company standards and industry best practices • Identify subrogation of claims and negotiate settlements • Manage mid-level general liability claims by gathering information to determine liability exposure • Assign reserve values to claims, making claims payments as necessary, and settling claims up to designated authority level • Assess liability and resolve claims within evaluation • Approve and process assigned claims, determine benefits due, and manage action plan pursuant to the claim or client contract • Manage subrogation of claims and negotiate settlements • Communicate claim action with claimant and client • Ensure claim files are properly documented and claims coding is correct • May process complex lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description This role offers the opportunity to manage complex, high-exposure construction defect claims while directly contributing to the operational success of a growing insurance platform. You will collaborate with internal teams, clients, and external partners to investigate claims, assess coverage, and negotiate settlements efficiently and fairly. The position requires strong analytical skills, legal understanding, and excellent communication to manage multiple high-value files with precision. You will also play a key role in mentoring junior staff, supporting process improvements, and ensuring compliance with industry regulations. This role provides a dynamic work environment where initiative, problem-solving, and attention to detail have a direct impact on both clients and organizational growth. - Adjust and manage complex construction defect claims, exercising judgment in applying legal liability and making settlement decisions within your authority. - Investigate losses thoroughly, gathering statements, contracts, expert reports, photos, and other documentation to establish claim validity. - Evaluate coverage, draft reservation of rights or denials, and maintain accurate documentation in each claim file. - Coordinate with defense counsel, independent adjusters, and experts to manage claims effectively. - Provide regular status updates to insureds, claimants, underwriters, and internal teams while resolving potential coverage questions. - Recommend or set reserves for claims and escalate high-exposure files to supervisors as needed. - Prepare written reports and ensure compliance with Fair Claims Practices and company policies. Qualifications - 5+ years of construction defect claims management experience preferred. - 10+ years of litigation management experience preferred. - College degree or equivalent claims management experience required. - Must hold an individual adjusting license for a designated home state and be willing to obtain additional licenses as needed. - Proficiency in Microsoft Office (Outlook, Word, Excel) and claims management systems. - Strong analytical, organizational, and problem-solving skills. - Excellent verbal and written communication with the ability to manage complex stakeholder relationships. - Ability to work independently, demonstrate judgment, and mentor junior team members. Benefits - Competitive salary: $82,000—$103,000 USD (based on experience and qualifications). - Comprehensive medical, dental, and vision insurance. - 401(k) plan with company match. - Paid time off and 11 company-paid holidays. - Employee ownership and referral programs. - Remote or hybrid work reimbursement and flexible work arrangements. - Professional development opportunities and financial wellness programs. - Short-term disability, life/AD&D insurance, voluntary supplemental benefits, and employee assistance programs.