Medical Claims Specialist: Career and Salary Facts

Find out about the types of jobs you could pursue as a medical claims specialist. Read on to learn more about career options along with salary and licensure information. Schools offering Risk Management degrees can also be found in these popular choices.

What Is a Medical Claims Specialist?

Medical claims specialists review healthcare-related insurance claims to determine if payments are due. You may work with patients and healthcare professionals to obtain complete and correct information. These professionals are also responsible for ensuring that both adjusters and claimants are complying with guidelines. Medical claims specialists determine if particular medical procedures are covered under a certain policy, and make sure that the procedure is necessary for the patient. They must often follow up to ensure that the procedure took place and the claim is not fraudulent. Sometimes medical claims specialists have to deny claims and explain the reasoning behind the denial. Learn more about this career option from the table below:

Degree Required H.S. diploma or G.E.D.
postsecondary training may be helpful
Education Field of Study Healthcare-related field
Key Responsibilities Evaluate insurance policies to determine coverage
Assist patient in filing claims
Contact patients and healthcare providers to clarify information
Licensure/Certification Certification is available
Job Growth (2014-2024)*3% (for all claims adjusters, examiners and investigators)
Mean Salary (2015)*$64,300 (for all claims adjusters, examiners and investigators)

Source:*U.S. Bureau of Labor Statistics

What Kind of Degree Do I Need to Become a Medical Claims Specialist?

Specialists generally need at least a high school degree, as well 1-2 years of experience in medical billing and or claims, as evident from a December 2011 search for medical claims specialist postings on Monster.com. Some training may be provided on the job, particularly on specialized software systems. You will need to keep up-to-date with changes in state and federal laws, insurance coverage and medical procedures.

To advance in this field, you may consider completing a certified medical insurance specialist course. You will generally need knowledge on medical records and coding, through professional experience or by completing coursework. Courses are available both online and through community colleges, and will cover topics similar to the following:

  • Insurance billing and coding
  • Office procedures
  • Medical terminology
  • Regulation compliance
  • Composition principles

What Will I Do?

Employers generally look for applicants who are organized and able to multi-task. Strong communication and interpersonal skills may also be necessary. Working as a medical claims specialist, you will handle all phases of a claim, including gathering reports, investigating and correcting any issues, collecting payments, determining coverage and closing files.

During the life of a claim, you may work with the patient and any medical personnel to obtain complete and correct information. You will also need to ensure that all legal and company guidelines are followed in the handling of a claim. If there is conflict over the claim, you may need to work with the attorneys who handle your firm's legal work.

How Much Will I Earn?

In May 2015, the U.S. Bureau of Labor Statistics reported that the mean salary for claims adjusters, examiners and investigators was $64,300. The projected growth rate from 2014 to 2024 for these professionals was 3%, which is slower than average. More claims can be handled by automated systems although personal oversight will always be needed. The number of healthcare claims is expected to increase as the population ages. Most medical claims specialists work a 40-hour week for health care providers or insurance or medical billing companies.

What Are Some Related Alternative Careers?

Automotive body and glass repairers and construction and building inspectors are some related positions that require a high school diploma or equivalent. Automotive body and glass repairers work to repair various aspects of damaged vehicles. This may include replacing windshields or door frames. Construction and building inspectors examine structures to ensure compliance with various building codes. They may also check for zoning requirements.

To continue researching, browse degree options below for course curriculum, prerequisites and financial aid information. Or, learn more about the subject by reading the related articles below:

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