Claims Examiner I

Marquette, MI - USA

Monthly Salary: Not Disclosed

Posted on: 30+ days ago

Vacancies: 1 Vacancy

Job Summary

DATE: October 7 2025

POSITION: Claims Examiner I

DEPARTMENT: Finance/Claims

BASE RATE: $16.32 per hour with potential for additional compensation based on qualifications.

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:

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

2. 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.

3. 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 $10000.

4. Meets or exceeds claim production goals as set by management while meeting or exceeding the department quality goals.

5. Resolves pended Medicaid professional and institutional claims on a daily basis; routes issues to the appropriate staff as required.

6. Processes mileage reimbursement requests accurately and timely.

7. Maintains daily production standards for claims entry and processing.

8. Responsible for submission and tracking of inpatient outlier claims.

9. Conducts claims research and identifies erroneous billing patterns and processing trends documents findings and communicates them to the appropriate UPHP staff.

10. Develops and maintains Standard Operating Procedures (SOP) for daily processes.

11. Assists the Claims Examiner II in the performance of their responsibilities; performs research and follow-up on escalated issues as needed.

12. Assists in training of new claims staff.

13. Attends conferences seminars and training sessions when required.

14. Maintains confidentiality of client data.

15. Performs other related duties as assigned or requested.

POSITION QUALIFICATIONS:

Education:

Minimum:

High school diploma or GED

Preferred:

Associate degree in health information processing office information systems business or related

field

Experience:

Minimum:

One (1) to three (3) years of 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 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

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

Ability to access all areas of the UPHP offices

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

Occasionally subjected to irregular hours

DATE: October 7 2025POSITION: Claims Examiner IDEPARTMENT: Finance/ClaimsBASE RATE: $16.32 per hour with potential for additional compensation based on qualifications.POSITION SUMMARY:This position is responsible for timely and accurate Medicaid claims entry and processing according to Upper Peninsu...