Claims Services Representative

Upper Peninsula Health Plan•Marquette, MI

2d•Onsite

About The Position

This position is responsible for resolving and responding to provider inquiries relating to claims and claims payment in accordance with organizational policies, regulatory requirements, and contractual obligations. This position supports all lines of business to include Medicaid, Medicare, and commercial. This position will communicate with providers about claims payment in an efficient and compassionate manner and in accordance with Upper Peninsula Health Plan (UPHP) policies and procedures. This role plays a critical part in ensuring providers are reimbursed correctly while supporting claims integrity and provider satisfaction.

Requirements

High School Diploma or GED
One (1) to two (2) years of medical office or claims/billing experience
Keyboarding proficiency
Working knowledge of MS Office (Word, Excel, and PowerPoint)
Exceptional human relation and oral/written communication
Excellent organizational and prioritization abilities with intense attention to detail
Ability to work independently and in a team environment

Nice To Haves

Associate degree in health information processing or related area
Coding certification
Medical office experience with knowledge of CPT, HCPCS, ICD-10 and UB-04 and CMS 1500 claim forms, Medicare claim processing manual, and Medical Services Administration (MSA) policies and claim processing manuals
Medical terminology

Responsibilities

Follows established Upper Peninsula Health Plan (UPHP) policies and procedures, objectives, safety standards, and sensitivity to confidential information.
Addresses all provider claims and payment-related inquiries including, but not limited to, benefits, eligibility, billing, and authorizations for all lines of business.
Develops relationships with providers and provider offices by providing general information related to billing and related policies, and excellent customer service.
Navigates multiple systems to investigate and resolve claims and claims payment issues; ensures timely resolution of inquiries received through various modalities, including phone, voicemail, email, and portals.
Identifies trends and systemic configuration issues; works closely with applicable department(s) to correct configuration and systems as necessary.
Reviews Michigan Department of Health and Human Services (MDHHS), Centers for Medicare and Medicaid Services (CMS) regulations, and UPHP policy, facilitating appropriate guidance and understanding of claims processing.
Researches and identifies trends in claims resubmissions and rejections; outreaches to providers to mitigate issues and/or to reduce rejected claims.
Identifies and documents erroneous billing behavior patterns and communicates them through appropriate processes when warranted.
Identifies and resolves member billing issues resulting from inaccurate claims processing, misunderstanding of remittance information, or other billing issues.
Completes all documentation and activities necessary to track, resolve, and report claims processing and payment.
Attends meetings as required with providers and/or UPHP staff to resolve provider reimbursement issues.
Maintains confidentiality of client data.
Performs other related duties as assigned or requested.