Claims Services Representative

DATE:  July 16, 2025

POSITION: Claims Services Representative      

DEPARTMENT: Operations - Provider Relations

BASE RATE: $15.92 per hour, with potential for additional compensation based on qualifications

POSITION SUMMARY:

This position is responsible for resolving and responding to provider inquiries relating to claims and claims payment for all lines of business to include Medicaid, Medicare, and commercial. This position will communicate with providers on the status of claims and claims payment in an efficient and compassionate manner and in accordance with Upper Peninsula Health Plan (UPHP) policies and procedures as well as state and federal rules and regulations. 

ESSENTIAL DUTIES AND RESPONSIBILITIES: 

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

1. Addresses all provider claims and payment-related inquiries including, but not limited to, benefits, eligibility, billing, and authorizations for all lines of business. 

1. Develops relationships with providers and provider offices by providing payment status on claims, general information related to billing and related policies, and excellent customer service. 

1. Navigates multiple computer systems to investigate and resolve claims and claims payment issues. 

1. Identifies trends and systemic configuration issues; works closely with applicable department(s) to correct configuration and systems as necessary. 

1. 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. 

1. Researches and identifies trends in claims resubmissions and rejections; outreaches to providers to mitigate issues and/or to reduce rejected claims. 

1. Identifies and documents erroneous billing behavior patterns and communicates them through appropriate processes when warranted. 

1. Completes all documentation and activities as necessary to track, resolve, and report claims processing and payment. 

1. Attends meetings as required with providers and/or UPHP staff to resolve provider reimbursement issues. 

1. Maintains confidentiality of client data. 

1. Performs other related duties as assigned or requested.

POSITION QUALIFICATIONS: 

Education: 

Minimum:       

Post high school vocational/specialized training

Preferred:       

Associate degree in health information processing or related area; coding certification 

Experience:

Minimum:       

One (1) to two (2) years of medical office or claims/billing experience

Preferred:

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. 

Required Skills:                                            

• 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 

Desired Skills:                                               

• Medical terminology                                   

The qualifications listed above are intended to represent the minimum skills and experience levels associated with performing the duties and responsibilities contained in this job description.  The qualifications should not be viewed as expressing absolute employment or promotional standards, but as general guidelines that should be considered along with other job-related selection or promotional criteria. 

Physical Requirements: 

[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 access departmental files


• Ability to enter and access information from a computer


• Ability to access all areas of the UPHP offices


• Moderate physical effort (lift/carry up to 25 pounds)


• Occasionally lifts supplies/equipment


• Occasional reaching, stooping, bending, kneeling, crouching


• Prolonged periods of sitting


• Occasional prolonged standing


• Manual dexterity and mobility 

Working Conditions:

• Works in office conditions, but occasional travel may be required


• Exposure to situations requiring periods of intense concentration


• Subject to many interruptions in a fast paced environment


• Subject to demand of high call answer rate