Medical claims processor keeping an eye on insurance claims

The name, Medical claims processor is well connected with healthcare financing. He is an expert who facilitates the later part of reimbursement procedure by handling the patients’ filled medical claims and verifies each medical procedure according to the patient’s insurance policy. He makes sure that the patient gets the actual medical coverage that justify his insurance policy.

An Overview:

Medical claims processors are generally employed by the hospitals, medical institutions, charity organizations, and clinics to deal with medical claims. The submitted claims are checked for the listed medical procedures enlisted against the insurance policy guidelines to validate for rules, conditions and eligibility of the insurer. Every insurance policy has its own set of rules and sometimes insurance is provided through multiple coverage to an individual or the benefactor. Some procedures may require prior authorization or a part of them only covered by the policy.

Medical Claims Processor Duties:

  • Enters details and acknowledge the medical claims received.
  • Carefully check every claim to ensure that it is properly filled up with information. If there is any missing or wrongly filled information, he takes necessary actions.
  • Effectively communicate with healthcare provider in the issues of eligibility, referral, insurance coverage, claim status and final payment.
  • Maintain the patients’ medical records with proper and corrective medical and procedural codes of CPT, ICD-9 codes.
  • Review the medical claims for the medical procedures covered and then entered the criteria for their validation in the patients’ claim record history through CRM.
  • Claims processor must maintain all the required information related to claims coverage and be able to substantiate them as evidence in case of medico-legal cases.

Career Opportunities for Medical Claims Processor:

Working as medical claims processors need not require any formal education, but it is advisable to attain some training programme. After being certified as medical claims processor, one can opt for the career options at various entry, medium and advanced levels. Some of these jobs are bundled with each other and also minimize on the formalities included which make it easy to opt for. These are listed as below:

  • Pre-Arrival Representative
  • Assessment Representative
  • Patient Business Service Representative
  • Medical Claims Processor
  • Medical Biller
  • Medical Coder
  • Medical Claims Technician
  • Accounts Receivable Specialist
  • Customer Service Representative
  • Reimbursement Assistant
Medical claims processor

Medical claims processor

Work Environment:

Medical claims processors working with government health agencies or private health institutions are required to have good communication skills, thorough understanding of different insurance policies and successful completion of certified training program in the pertinent field. An experience in the field is always advantageous. The medical claims processor should have good knowledge of local, state and federal laws related to insurance coverage. Some insurance policies such as Medicaid and Medicare are implemented differently in each U.S. state. He/she should have proficiency in using office automation systems including MS office and observe strong work ethics to ensure the confidentiality of the patients’ medical records. The work and expectation from the medical claims processor working with small health agencies, clinics or the doctor’s office might be a little different. The medical claims processor have multiple responsibilities, including helping the patients to fill the proper insurance forms. He/she may require to follow a more comprehensive communication for requesting the patients to provide the proper information or collect their dues within the specified duration. His/her responsibilities include upholding the doctor-patient relation by providing better insurance coverage services.

Skills Needed to Perform the Job

Not just anybody can be a medical claim processor. Here are a few skills that will be helpful in your new endeavor:

  • Knowledge of the health insurance industry
  • Good communication skills
  • Understanding health coding and medical terminology
  • Excellent attention to detail

If you’ve got experience in the medical field already, you’ve got a leg up. However, there is plenty of research material out there that can help you learn the skills you need.

Medical claims processor keeping an eye on insurance claims
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Medical claims processor keeping an eye on insurance claims
Medical claims processor is an expert who facilitates the later part of reimbursement procedure by handling the patients’ filled medical claims.
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  1. Yamary June 30, 2017

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