Claims Examiner I

DEPARTMENT: Finance/Claims POSITION SUMMARY: 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. ESSENTIAL DUTIES AND RESPONSIBILITIES: Follows established Upper Peninsula Health Plan policies and procedures, objectives, safety standards, and sensitivity to confidential information. ```{=html} ``` 1. 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. ```{=html} ``` 1. 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. ```{=html} ``` 1. Meets or exceeds claim production goals as set by management while meeting or exceeding the department quality goals. ```{=html} ``` 1. Resolves pended Medicaid professional and institutional claims on a daily basis; routes issues to the appropriate staff as required. ```{=html} ``` 1. Maintains daily production standards for claims entry and processing. ```{=html} ``` 1. Conducts claims research and identifies erroneous billing patterns and processing trends, documents findings and communicates them to the appropriate UPHP staff. ```{=html} ``` 1. Develops and maintains Standard Operating Procedures (SOP) for daily processes. ```{=html} ``` 1. Assists the Claims Examiner II in the performance of their responsibilities; performs research and follow-up on escalated issues as needed. ```{=html} ``` 1. Assists in training of new claims staff. ```{=html} ``` 1. Attends conferences, seminars and training sessions when required. ```{=html} ``` 1. Maintains confidentiality of client data. ```{=html} ``` 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, office information systems, business or related field Experience: Minimum: One (1) to three (3) years claims experience or equivalent combination of experience and education Preferred: Knowledge of third-party billing, coordination of benefits, medical claims processing, CPT, HCPCS, ICD-10, coding rules, and DRG & APC methodologies Required Skills: ### Keyboarding proficiency with working knowledge of Microsoft Office Suite (Word, Excel, Access, 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 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 funct