Alyssa Lane
Medical claims specialists and examiners are responsible for obtaining and processing medical insurance claim information for healthcare providers and patients. They work directly with insured clients, helping them understand their insurance coverage and examine and resolve medical claims. They also ensure that all claims are processed within company and legal guidelines. In addition to excellent customer service skills, medical claims specialists and examiners need to be detail-oriented, analytical, and have good people skills. While there are no standard qualification requirements, most employers prefer candidates with at least a high school diploma or equivalent, and some require a bachelor's degree or insurance-related work experience.
| Characteristics | Values |
|---|---|
| Work setting | Office, call centre, or remote |
| Work hours | 35-40 hours per week, shifts may include nights, weekends, and holidays |
| Education | High school diploma, bachelor's or associate's degree in Business, Economics, Mathematics, Information Technologies, or Statistics |
| Skills | Customer service, sales, communication, analytical, investigation, negotiation, problem-solving, and legal knowledge |
| Experience | Entry-level positions available, previous experience in retail, administration, or customer service is advantageous |
| Career progression | Senior claims handler, claims team leader, claims supervisor, claims manager, branch manager, claims director |
| Salary | £32,000-£45,000 for claims managers, £60,000+ for senior claims managers, £100,000+ for claims directors and head of claims |
| Benefits | Company car, medical insurance, life insurance, discounted insurance premiums, profit share, pension scheme, bonuses |
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What You'll Learn
Education and qualifications
While there are no formal education requirements to become a medical claims processor, most employers prefer candidates with at least a high school diploma or equivalent, and many will provide on-the-job training. You can also pursue a vocational, associate's, or bachelor's degree to make yourself more competitive. A business degree can be particularly useful if you intend to run your own medical claims processing business.
Consider earning a degree in business, accounting, information technology, or a medical field to gain skills that could help you in this role and impress potential employers. A Clinical Medical Assistant (CMA) associate degree, for example, can provide a strong foundation in medical terminology, anatomy, and procedures, allowing you to accurately interpret medical records.
In addition to a degree, you can also earn professional certifications that will help you become a medical insurance claims processor. Gaining certifications can build your skills and increase your chances of earning a higher salary. For example, you can become a Certified Professional Coder (CPC) by passing an exam offered by the American Academy of Professional Coders (AAPC).
To prepare for a career as a medical claims processor, you should develop a working knowledge of ICD-9 and ICD-10 procedure codes, Current Procedural Terminology (CPT), and insurance verification practices. You can enrol in short-term training to understand how to read and interpret these codes and take online courses in medical billing and processing.
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Day-to-day responsibilities
Day-to-day, medical insurance claims processors are responsible for handling billing and insurance claim paperwork for healthcare offices or insurance companies. They ensure that medical insurance claims have the correct billing codes that match the services provided. They also clarify patient concerns about benefits and add any changes made to the claim by doctors or the insurer. Claims processors may also need to follow up with the insurer to find out the status of claims and discuss any discrepancies.
A key aspect of the role is to ensure the accuracy and validity of a medical claim. This involves gaining a working knowledge of ICD-9 and ICD-10 procedure codes, current procedural terminology (CPT), and insurance verification practices. They need to review finalized EOBs (Explanation of Benefits) and issue them to the appropriate insured/claimant, provider, and/or insurance carrier. They also process reimbursements to vendors and veterans and submit Medicare and Medicaid claims electronically for payment.
Claims processors are also responsible for processing claims forms, adjudicating the allocation of deductibles and copays, and following through with adjudication policies to facilitate the proper payment of claims. They enter UB 92 and 1500 HCFA medical claims into the computer system and manage and process insurance claims. They also submit medical claims to commercial insurance companies, Medicare, and Medicaid for payment, using ICD-9 and CPT coding. They review and verify patient account information against insurance program specifications and analyze surgical procedures and diagnoses using CPT-4 and ICD-9 codes.
Additionally, claims processors study a policyholder's insurance claim history to ensure their insurance rate and claim payment are accurate. They verify insurance policy coverage and check that client information is accurate. Once a covered loss is determined, they document the information and ensure all the required paperwork is complete. They also process new insurance policies, modify existing ones, and obtain information from policyholders to verify their accounts' accuracy.
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Career prospects and salary expectations
While there are no standard qualification requirements for medical insurance claims examiners, most employers prefer a high school diploma or equivalent. Other employers seek candidates with a bachelor's degree, preferably in a medical or life sciences field. Some employers may also require certification by the International Claim Association (ICA). Additionally, some prior work experience in insurance or medical fields is highly valued by prospective employers. Obtaining a Clinical Medical Assistant (CMA) associate degree is another way to gain the necessary knowledge and skills to become a medical insurance claims examiner.
The salary expectations for medical insurance claims examiners vary depending on location and level of experience. The average annual salary for medical claims examiners in the United States is around $34,615 to $42,773, with an hourly wage of about $17 to $21. However, salaries can range from $30,000 to $59,000 per year. In certain states, such as California, New Jersey, and Massachusetts, medical claims adjusters tend to earn higher salaries. For example, the average salary for a medical claims adjuster in the District of Columbia is $78,577.
For senior-level positions in the field, salaries can range from $80,000 to $97,000 with 4-5 years of experience. In some cases, such as in large loss, general adjuster, marine, and cargo positions, salaries can exceed $120,000 with sufficient experience and the right firm.
It is important to note that the employment of medical insurance claims examiners is projected to decline by 5% from 2023 to 2033, according to the US Bureau of Labor Statistics. However, there will still be a significant number of openings each year due to the need to replace workers who transfer or retire. Additionally, the increasing number of natural disasters and the advancements in technology may also impact the career prospects and salary expectations for medical insurance claims examiners.
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$114.46 $245.95
Required skills and attributes
To become a medical insurance claims processor, you will need a mix of technical, administrative, and interpersonal skills.
Technical Skills
- Computer literacy: Proficiency in basic computer software and word processing systems is essential. Claims processors must be able to use data entry software, download email attachments, and perform data entry functions. Familiarity with Windows-based software and medical billing and claims processing software is also beneficial.
- Knowledge of coding systems: Understanding of Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) coding systems is crucial for interpreting medical reports and billing. This includes knowledge of ICD-9 and ICD-10 procedure codes.
- Understanding of healthcare regulations: Familiarity with healthcare laws, HIPAA rules, and regulatory compliance is important to ensure claims are processed correctly and confidentially.
Administrative Skills
- Attention to detail: Accuracy and precision are critical in this role, as claims processors must verify information, review medical reports, and ensure proper billing codes.
- Organization: Claims processors need to manage and track insurance claims, maintain records, and follow up on the status of claims.
- Time management: Handling multiple claims efficiently and meeting deadlines require effective time management skills.
Interpersonal Skills
- Communication: Strong communication skills, both oral and written, are essential for interacting with doctors, patients, insurers, and colleagues.
- Customer service: Claims processors should be able to provide clear and helpful responses to patient inquiries, address concerns, and effectively resolve issues.
- Problem-solving: Critical thinking and analytical abilities are valuable for identifying solutions, particularly when clarifying discrepancies or interpreting complex medical information.
While not always necessary, some employers may prefer candidates with a high school diploma or equivalent, and additional certifications or degrees in related fields can enhance your competitiveness for these roles.
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Pros and cons of the role
Pros and Cons of Being a Medical Insurance Claims Specialist
A medical insurance claims specialist is responsible for gathering and processing the information required to complete the medical insurance claims process. They play a crucial role in the healthcare industry by helping insured clients understand their insurance coverage, examining and resolving medical claims, and ensuring that all claims are processed within company and legal guidelines.
Pros
The role of a medical insurance claims specialist offers a stable work schedule, typically Monday through Friday, with no overtime or work on holidays. The work environment is usually comfortable, with air-conditioned offices or cubicles. The role can be relatively easy, as it does not require heavy lifting or being on your feet for long periods. It can be a well-paid position, with the top 10% of claims specialists earning about $44 per hour. The job provides an opportunity to develop a large professional network over time, which can lead to new career opportunities and increased earning potential.
Cons
Selling insurance can be challenging, as it often involves convincing people that they need a particular product and not taking "no" for an answer. The work can be sedentary, with long hours spent sitting in front of a computer or on the phone. The role may also involve working in a small cubicle, which can be boring. There may be limited career growth opportunities, and the work requires keeping up with ongoing training and a high volume of claims.
Overall, the role of a medical insurance claims specialist offers a stable and comfortable work environment, good earning potential, and opportunities for professional development but may involve challenging sales targets, a sedentary lifestyle, and limited career progression.
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Frequently asked questions
A high school diploma or GED is typically required to become a medical insurance claims processor. While a post-secondary degree is not necessary, some insurance companies may prefer candidates with a vocational, associate's, or bachelor's degree in a relevant field. Relevant degrees include business, accounting, information technology, or a medical field.
Although not always required, obtaining certifications can increase your competitiveness and earning potential. Relevant certifications include Certified Medical Reimbursement Specialist (CMRS) and Certified Professional.
Strong communication, analytical, and customer service skills are essential for this role. Additionally, proficiency in data entry, basic computer software, and word processing systems is important. Knowledge of medical terminology, billing procedures, and insurance policies is also crucial.
Medical insurance claims processors handle medical billing and coding, process claims forms, allocate deductibles and copays, and follow adjudication policies to ensure proper claim payments. They may also research and verify claims, communicate with doctors and patients, and manage cases.
