Claims Services Representative

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