DATE: August 18, 2026
POSITION Claims Services Representative
DEPARTMENT: Operations - Provider Relations
BASE RATE: $18.50 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 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.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Follows established Upper Peninsula Health Plan (UPHP) policies and procedures, objectives, safety standards, and sensitivity to confidential information.
2. Addresses all provider claims and payment-related inquiries including, but not limited to, benefits, eligibility, billing, and authorizations for all lines of business.
3. Develops relationships with providers and provider offices by providing general information related to billing and related policies, and excellent customer service.
4. 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.
5. Identifies trends and systemic configuration issues; works closely with applicable department(s) to correct configuration and systems as necessary.
6. 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.
7. Researches and identifies trends in claims resubmissions and rejections; outreaches to providers to mitigate issues and/or to reduce rejected claims.
8. Identifies and documents erroneous billing behavior patterns and communicates them through appropriate processes when warranted.
9. Identifies and resolves member billing issues resulting from inaccurate claims processing, misunderstanding of remittance information, or other billing issues.
10. Completes all documentation and activities necessary to track, resolve, and report claims processing and payment.
11. Attends meetings as required with providers and/or UPHP staff to resolve provider reimbursement issues.
12. Maintains confidentiality of client data.
13. Performs other related duties as assigned or requested.
POSITION QUALIFICATIONS:
Education:
Minimum:
High School Diploma or GED
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 enter and access information from a computer
Occasionally lifts supplies/equipment
Prolonged periods of sitting
Manual dexterity
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
Salary :
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