Eligibility Administrator

Imagine360 is seeking a Eligibility Administrator to join the team! The Eligibility Administrator is responsible for the accurate and timely administration of member eligibility for assigned client groups. This role serves as a key operational resource, ensuring that member enrollment information is maintained in accordance with client requirements, plan documents, company policies, and regulatory standards. The Eligibility Administrator manages a daily workload of eligibility transactions, validates enrollment information, researches discrepancies, and collaborates with clients, brokers, and internal teams to ensure members are enrolled correctly and receive the appropriate benefits coverage.The primary responsibility of the Eligibility Administrator is the review and processing of member eligibility transactions from a variety of sources, including internal systems, client submissions, email requests, electronic data files, and client portals.

Position Location: 100% remote

Responsibilities include but are not limited to:

Eligibility Transaction Processing

• Process new member enrollments accurately and within established service standards.
• Review and processing member terminations.
• Process eligibility changes such as demographic updates, plan changes, dependent additions or removals, and status changes.
• Process reinstatements when previously terminated members regain eligibility.
• Process Coordination of Benefits, other insurance coverage requests.
• Update COBRA eligibility in partner system.
• Manage a designated portfolio of client groups and ensure all requests are completed accurately and on time.
• Review plan documents, fact sheets, benefit summaries, and plan recaps to verify eligibility requirements.
• Apply client-specific eligibility rules according to plan documents.
• Ensure that enrollment decisions are consistent, accurate, and properly documented in file system.

Client Support

• Respond to eligibility inquiries from clients, brokers, and trading partners.
• Research eligibility concerns and resolving enrollment discrepancies.
• Collaborate with Client Experience, Member Experience, and other operational teams to resolve client concerns.
• Maintain professional communication when addressing member and client concerns.

Quality Assurance and Performance Management

• Review production metrics on a consistent basis.
• Meet daily, weekly, and monthly transaction goals.
• Maintain established service level and turnaround time expectations.
• Achieve monthly quality score goals established by the department.

Required Experience/Education:

• High School Diploma or GED
• 2-4 years of operations experience required or equivalent combination of education and experience.

Skills and Abilities:

• Experience interpreting large data sets and identifying discrepancies.
• Advanced Microsoft Excel skills, including data manipulation, validation, and reporting.
  • Proficiency with Microsoft Lists. Excel and related Microsoft Office applications.
  • Working knowledge of Word, PowerPoint, Visio, and Copilot.
• Ability to navigate multiple systems efficiently.
• Strong verbal and written communication skills.
• Ability to explain complex eligibility concepts to clients and internal teams.
  • Professional customer service approach when handling escalated eligibility concerns.
  • Comfortable interacting with clients, brokers, and operational departments.
• Effective time-management and prioritization skills.
• High level of accuracy and attention to detail.
• Strong organizational and documentation skills.
• Follow HIPAA guidelines and protect confidential member information.
• Adhere to established eligibility processes and operational procedures.
• Maintain compliance with company standards for quality, documentation, and client service.
• Participate in team meetings, training sessions, quality reviews, and continuous improvement initiatives.

What can Imagine360 offer you?

• 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

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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**