Upper Peninsula Health Plan

This position is responsible for compiling, analyzing, trending, tracking, and interpreting all Medicare-Medicaid Plan, Medicaid, and TPA enrollment activities and is responsible for researching, interpreting, analyzing, and correcting all pended and rejected Medicaid and Medicare encounters including complex encounter issues in accordance with contract guidelines. 

1. Follows established UPHP policies and procedures, objectives, safety standards, and sensitivity to confidential information.

 

2. Ensures data integrity and accuracy in all enrollment and encounter processes through analysis of potential system issues with the 834 and 837 transactions. Serves as the subject matter expert and liaison for 834 audit and daily file reconciliations with the Michigan Department of Health & Human Services (MDHHS); participates in the enrollment and encounter workgroup meetings as necessary.

 

3. Responsible for accurate revenue reconciliation of payment transactions to enrollment records through analysis of potential system issues with the 820 records, including monthly missing and overpayment reports.  Collaborates with the Finance Department to resolve capitation payment rate issues.

 

4. Submits Medicaid service requests through the Community Health Automated Medicaid Processing System (CHAMPS) to MDHHS regarding enrollment and/or payment issue discrepancies as well as MI Coordinated Health (MICH) discrepancies and immediate access of care issues between the Center for Medicare and Medicaid Services (CMS) and MDHHS.  

 

5. Oversees and works closely with the encounter vendor and internal staff to ensure the accurate and timely submissions of encounter data and analyzes and resolves claim pends and rejections for acceptance at CMS and MDHHS. Acts as liaison with business partners regarding 837 encounter data requirements, including 999 and 277CA acknowledgment files, ETRR (4950, 6502, 6503) files and the MAO-002.

 

6. Responsible for the day-to-day resolution of verbal and written inquiries regarding enrollment, encounter, and newborn activities from other staff, providers, and members, and works closely with claims and pharmacy staff assessing and confirming that all incoming enrollment, provider, and claims data is accurate and complete.

 

7. Review and reconcile the weekly out to hospital (OTH) movements report. Compile, reconcile, 

document and notify WI Medicaid and apply for Wisconsin Medicaid timely on behalf of TPA Client, WI Department of Corrections, while they are inpatient status.  

 

8. Verifies and reconciles that Maternity Case Rate (MCR) payments have been received for all qualifying births and that newborns are enrolled with UPHP appropriately.

 

9. Serves as Domain Administrator for CHAMPS.

 

10. Oversees the process that generates member ID cards, new member packets, PPD, EOC, Formulary Requests, and Medicaid Handbooks, ensuring accurate and timely mailings. Validates health plan material mailings by the print vendor, verifies vendor invoices, and ensures print vendor compliance with our contract.  

 

11. Works closely with the Senior Programmer to interpret, analyze, test and validate all 834 enrollment file and 837 encounter file change to accommodate MDHHS and/or CMS requirements.

 

12. Serves as enrollment and encounter data subject matter expert for audits and compliance reviews.

 

13. Works with the Risk Adjustment Analyst & Coding Compliance Auditor to interpret and correct errors within the Encounter Data Processing Systems (EDPS).

 

14. Works closely with the Compliance Department and external vendors to identify and validate accurate claim encounter activity for Program Integrity submissions to MDHHS.

 

15. Maintains written documentation of all activities and revises procedures and policies to increase efficiency and accommodate any changes.

 

16. Maintains confidentiality of client data.

 

17. Performs other related duties as assigned or requested.

Associate degree in health information processing, computer information systems, accounting, 

business, or related field; five (5) years of relevant experience in lieu of a degree will be 

considered

 

Bachelor’s degree in health information management, computer information systems, accounting, or related field

 

Two (2) to four (4) years of claims management, information systems, accounting, or relevant experience

 

Four (4) to six (6) years of experience reporting, analyzing, interpreting and presenting data; experience analyzing large data files and performing file reconciliations; knowledge of CPT, HCPCS, ICD-10 coding; revenue codes; DRG, UB-04 and CMS-1500 claims submission and electronic claims submissions; APC reimbursement methodology: and MSA and CMS policy

Keyboarding proficiency and working knowledge of MS Office (Word, Excel, Access, and Power Point)

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

 

Oriented to managed care and health care systems

 

 

 

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

Exposure to clients and others who may require exceptional interpersonal skills

Subject to many interruptions

Occasional travel may be required