Upper Peninsula Health Plan

BASE RATE: $16.32 per hour, with potential for additional compensation based on qualifications. 

This position is responsible for timely and accurate Medicaid claims entry and processing according to Upper Peninsula Health Plan (UPHP) policies and procedures and in compliance with regulatory guidelines and must maintain the minimum productions standards.

1. Follows established Upper Peninsula Health Plan policies and procedures, objectives, safety standards, and sensitivity to confidential information.

 

2. Maintains a thorough knowledge of proper claims submission and coding rules with application of unique UPHP processes and benefit plan administration for Medicaid product lines and other medical benefits or services.

 

3. Processes claims in accordance with the plan benefits, authorization requirements, coordination of benefits, subrogation and state insurance mandates up to the designated high dollar claim approval limit of $10,000.

 

4. Meets or exceeds claim production goals as set by management while meeting or exceeding the department quality goals.

 

5. Resolves pended Medicaid professional and institutional claims on a daily basis; routes issues to the appropriate staff as required.

 

6. Processes mileage reimbursement requests accurately and timely. 

 

7. Maintains daily production standards for claims entry and processing.

 

8. Responsible for submission and tracking of inpatient outlier claims.

 

9. Conducts claims research and identifies erroneous billing patterns and processing trends, documents findings and communicates them to the appropriate UPHP staff.

 

10. Develops and maintains Standard Operating Procedures (SOP) for daily processes. 

 

11. Assists the Claims Examiner II in the performance of their responsibilities; performs research and follow-up on escalated issues as needed.

 

12. Assists in training of new claims staff.

 

13. Attends conferences, seminars, and training sessions when required.

 

14. Maintains confidentiality of client data.

 

15. Performs other related duties as assigned or requested.

High school diploma or GED

 

Associate degree in health information processing, office information systems, business, or related 

field

 

One (1) to three (3) years of claims experience or equivalent combination of experience and 

education

 

Knowledge of third-party billing, coordination of benefits, medical claims processing, CPT, 

HCPCS, ICD-10, coding rules, and DRG & APC methodologies

 

Keyboarding proficiency with working knowledge of Microsoft Office Suite (Word, Excel, and 

PowerPoint)

Knowledge of health plan programs, benefits, and services for all lines of business for our members

Knowledge of customer relations and team participation

Excellent human relation and oral/written communication

Excellent organizational abilities with attention to detail

Medical terminology

Ability to work independently and to prioritize tasks with minimal supervision

 

[This job requires the ability to perform the essential functions contained in the description. These include, but are not limited to, the following requirements. Reasonable accommodations may be made for otherwise qualified applicants unable to fulfill one or more of these requirements]:

 

Ability to enter and access information from a computer

Ability to access all areas of the UPHP offices

Occasionally lifts supplies/equipment

Prolonged periods of sitting

Manual dexterity 

 

Works in office conditions, but occasional travel may be required

Exposure to situations requiring periods of intense concentration

Subject to many interruptions

Occasionally subjected to irregular hours