Midwest Health Plan
Position Title:
Requisition #:
Status:
Shift:
Department:
Location:
Claims Analyst II
84903
Full time, 40 hours per week
Days
Claims
Dearborn
General Summary:
This position supports the Claims department by functioning as a resource to provide technical assistance
and claims responses for high level problems, responsible for processing claims accurately and within the
compliance timelines, answering health plan provider phone inquiries relating to claims, benefits, and
Health Plan policies, responsible for developing and maintaining working relationships with internal
departments and MHP Providers and meeting department’s production and quality goals. Dependable
attendance is a necessity due to the critical nature of the job function.
Principal Duties and Responsibilities:
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Act as a resource and assists the Claims Managers in the daily operational flow of the claims
production staff.
Research, process, adjust, edit and efficiently analyze claims pre and post payment.
Monitor the number of outstanding pended claims by managing daily turnaround times and work
the assigned claim queues
Assures that claims are adjudicated within the timeframes to allow the department to comply with
the required turnaround times.
Identify claims that are considered to be unusual and require additional research by requesting
medical records, office notes, and ER notes prior to adjudication to the attention of the claims
management team.
Seek assistance and guidance in a timely fashion from the claims management team as
necessary after first consulting the claims processing reference material when working on claims
issues.
Adherence to quality standards and maintain high quality claim audit results standards
Answer provider calls to address any claims related issues
Work project as assigned by claims management
Other duties as assigned.
Education Required:
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High school diploma with some college courses plus related work experience
Knowledge of claims processing systems
Proficiency in Microsoft Office and emails
Knowledge of principles of telephone etiquette
Preferred:
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Associate degree or working on an associate degree
Health care industry experience in general and managed care in particular
Data analysis using Microsoft excel tools or any report generating tool
Experience Required:
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Proficiency in ICD-9, CPT, and HCPCS coding and Medical/Dental Terminology
Must have CMS 1500 and UB 04 insurance claims experience and expertise.
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Midwest Health Plan
Position Title:
Requisition #:
Status:
Shift:
Department:
Location:

Claims Analyst II
84903
Full time, 40 hours per week
Days
Claims
Dearborn
Five to ten years of prior work experience preferably in healthcare as a claims analyst or medical
billing in a high volume computerized environment
Preferred:
 Medical Health CMS 1500 and UB 04 insurance claims experience.
 At least three (3) years of experience in claim service area within Medicare, Medicaid Managed
Care Organizations, or related insurance fields is required.
Certifications/Licensures Required:
Assessments:
Skills and Abilities:
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Accurate typing skills with high level of data entry accuracy and good math aptitude
Must be organized, professional and have excellent verbal and written communication skills.
Must project a professional image even when managing difficult situations
Strong dedicated customer service focus
Team Member Standards of Excellence:
Must meet or exceed core customer service responsibilities, standards and behaviors as summarized
below:
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Display a positive attitude
Take ownership and be accountable
Offer open and constructive communication
Respond in a timely manner
Take pride in the system
Respect and be sensitive to privacy/confidentiality
Commit to team members
Honor and respect diversity
Maintain a clean and safe workplace environment
Physical Demands/Working Conditions:
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Ability to carry or move less than 20 pound packages
Ability to sit for a long period of time
Constantly work on computer
Ability to answer provider phone calls and work the claims
Some local travel for training purposes
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