If you have ever filed a health insurance claim, you may have wondered who reviews it and decides whether to pay or deny it. The answer is a medical claims examiner, a professional who plays a vital role in the health care system. In this article, you will learn what a medical claims examiner does, what skills and qualifications they need, and what challenges and opportunities they face in their career.
A medical claims examiner is someone who evaluates and processes health insurance claims submitted by health care providers or policyholders. They check the accuracy and completeness of the claim forms, verify the eligibility and coverage of the claimant, and apply the rules and regulations of the insurance plan. They also communicate with providers, policyholders, and other parties to resolve any issues or discrepancies, and authorize or reject payments based on their findings.
A medical claims examiner reviews healthcare claims to ensure accuracy and compliance with policies. They evaluate the validity of claims, verify coverage, and ensure proper billing practices.
To become a medical claims examiner, you typically need a high school diploma or equivalent, and some experience or training in medical billing and coding, health insurance, or health care administration. You also need to have strong analytical, communication, and computer skills, as well as attention to detail and accuracy. Some employers may prefer candidates who have an associate's or bachelor's degree in a related field, or a certification from a professional organization, such as the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA).
Medical claims examiners need analytical skills to evaluate claims, attention to detail for accuracy, knowledge of healthcare coding and billing, and familiarity with insurance policies and regulations. A bachelor's degree in a related field is often required.
A medical claims examiner's primary roles involve reviewing and verifying health insurance claims for accuracy, completeness, and conformity with the plan's policies and procedures. They must also research and resolve any discrepancies in the claim data, such as missing information, incorrect codes, or duplicate charges. Additionally, they must ascertain the claimant's eligibility and coverage, apply the applicable deductibles, copayments, coinsurance, and other adjustments, authorize or reject payments for the claims, and generate explanation of benefits (EOB) statements or denial letters. Furthermore, they must communicate with health care providers, policyholders, and other parties to answer questions or explain the claim status or decision. Additionally, they must maintain accurate records of the claim files and update the claim system with relevant information. It is also important that they adhere to federal, state, and industry laws and regulations regarding health insurance and privacy.
A medical claims examiner reviews healthcare insurance claims, verifying eligibility and coverage, ensuring billing accuracy, and determining claim approval or denial based on policy guidelines and medical necessity.
Their duties include reviewing medical claims, verifying insurance coverage, ensuring compliance with regulations, identifying discrepancies or fraud, and communicating with healthcare providers and policyholders to resolve issues.
This is quite a very challenging role in that it demands your 100%attention for accurate reports. Picking all the missing information, incorrect codes,duplicate of charges or claims above all meetings the deadlines.
A medical claims examiner may face some challenges and opportunities in their career, such as working under pressure and deadlines while handling a high volume of claims with various complexities. It is also important to stay up-to-date with the changes in the health insurance and health care industry, like new codes, policies, and regulations. To further develop their skills and knowledge, they should take advantage of continuing education, training, and certification programs, which may improve their career prospects and advancement opportunities. Additionally, they should collaborate with other professionals in the health care system to ensure the quality and efficiency of the claim process. Lastly, they can contribute to the improvement of the health care system by ensuring accuracy and fairness of payments while preventing or detecting fraud, waste, and abuse.
Challenges include staying updated with changing healthcare regulations and dealing with complex claims. Opportunities arise in advancing to senior roles and contributing to the efficiency of healthcare billing processes.
According to the U.S. Bureau of Labor Statistics (BLS), the median annual wage for medical claims examiners and investigators was $66,540 in May 2019, and the projected job growth for this occupation was 4% from 2019 to 2029, which is about as fast as the average for all occupations. However, the salary and outlook may vary depending on the employer, location, education, experience, and certification of the medical claims examiner. Medical claims examiners may work for health insurance companies, government agencies, health care facilities, or third-party administrators. They usually work in an office setting, but some may work remotely or travel to conduct audits or investigations.
Earnings vary by location and experience, but the median annual wage is around $40,000 to $60,000. They work in insurance companies, healthcare institutions, and government agencies.
A medical claims examiner reviews health insurance claims to verify their accuracy and compliance with policies, determines coverage, authorizes payments, investigates discrepancies, and communicates with healthcare providers and policyholders.