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Medical claims examiners review insurance claims by medical patients. Their primary job focus is to decide if the claim qualifies for payment by a health insurance carrier, a government agency or another healthcare management service.

Medical claims are evaluated by medical claims examiners to make sure they are accurate and complete. If there is information missing from the claim, it may be returned to either the insured or the medical office to attain complete information. Claims examiners will also evaluate the claim against the insured’s policy to see if it matches the procedure or service performed by the medical facility. Through this process, the medical claims examiner is trying to determine if the claim is eligible for payment under the policy and what that payment may be. If the claim is in dispute, the claims examiner may also have to contact the insured and the medical office for additional details.

After the medical claims reviewer has gathered all the information about the insurance claim, then it is their job to make a determination of whether to pay, deny or submit the claim for further evaluation.

Necessary Skills to Become a Medical Claims Examiner

Most medical claims examiners work in an office environment so proficiency in office equipment and technical skills are a must. In most cases, the job requires the use of a computer and general office programs like word processing, email, and use of the internet. The job may also require the use of specific software that is utilized by the employer. Filing, report writing and reading, typing, attending meetings and speaking on the phone are also skills that may be necessary in this profession.

More specialized skills necessary in this field are understanding medical technology and insurance codes, policies and procedures. A working knowledge of the processes of healthcare facilities, hospitals and treatment centers is also valuable. Medical claims examiners must work with patients and medical offices, often dealing with complaints. For this reason the job may require one to interact with attorneys, attend mediation hearings and work with employers.

Education for Medical Claims Examiner

There is no formal program of training for the position. However, it is recommended that workers in the field obtain education in a business-related educational program and acquire experience in the insurance and/or healthcare fields. Many places of employment may provide training to employees with either education or training in a similar field.

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