Claims Examiner I

Upper Peninsula Health Plan•Marquette, MI

1d•$16

About The Position

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.

Requirements

High school diploma or GED
One (1) year of experience in healthcare, insurance, or other office administrative work involving data entry, financial transactions, or claims- or billing-related processes.
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

Nice To Haves

Associate degree in health information processing, office information systems, business, or related field
Knowledge of third-party billing, coordination of benefits, medical claims processing, CPT, HCPCS, ICD-10, coding rules, and DRG & APC methodologies

Responsibilities

Follows established Upper Peninsula Health Plan policies and procedures, objectives, safety standards, and sensitivity to confidential information.
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.
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.
Meets or exceeds claim production goals as set by management while meeting or exceeding the department quality goals.
Resolves pended Medicaid professional and institutional claims on a daily basis; routes issues to the appropriate staff as required.
Processes mileage reimbursement requests accurately and timely.
Maintains daily production standards for claims entry and processing.
Responsible for submission and tracking of inpatient outlier claims.
Conducts claims research and identifies erroneous billing patterns and processing trends, documents findings and communicates them to the appropriate UPHP staff.
Develops and maintains Standard Operating Procedures (SOP) for daily processes.
Assists the Claims Examiner II in the performance of their responsibilities; performs research and follow-up on escalated issues as needed.
Assists in training new claims staff.
Attends conferences, seminars, and training sessions when required.
Maintains confidentiality of client data.
Performs other related duties as assigned or requested.