Medical Claims Specialist Careers: Job Description & Salary Info

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What are the pros and cons of a medical claims specialist career? Get real job descriptions, career prospects and salary info to see if becoming a medical claims specialist is right for you.
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Pros and Cons of a Medical Claims Specialist Career

A medical claims specialist, also known as a health claims specialist, works with healthcare organizations to prepare and process insurance claims for reimbursement. Read on to learn more about the pros and cons of becoming a medical claims specialist to see if it's right for you.

Pros of Becoming a Medical Claims Specialist
Solid expansion in the field (projected employment growth of 22% between 2012-2022)*
Can obtain entry-level employment with minimal postsecondary education*
Can work in a variety of healthcare settings (doctors' offices, hospitals, medical groups, insurance companies, etc.)*
Usually work in comfortable office settings*

Cons of Becoming a Medical Claims Specialist
Professional certifications are often required by employers*
Relatively low earnings potential (mean salary around $39,000 as of 2014)*
May require continuing education to stay current on laws, regulations and coding practices*
Requires meticulous attention to detail and accuracy**
Working with disgruntled claimants and policyholders can be stressful*

Sources: *U.S. Bureau of Labor Statistics, **O*Net OnLine.

Career Information

Job Description

Medical claims specialists work for healthcare organizations to prepare and process claims for reimbursement. They review patient files to make sure diagnoses are properly coded and that the information is complete. If details are incorrect or missing, the medical claims specialist confers with care providers and health records information technicians to obtain the right information. Medical claims specialists also work for insurance providers and medical billing companies, where they process claims to determine eligibility for reimbursement based on the treatment provided and the coverage outlined by the patient's policy.

Salary Info and Career Outlook

Salary figures for medical claims specialists may vary depending on the work setting. As reported by the U.S. Bureau of Labor Statistics (BLS), medical records and health information technicians tend to work for medical practices and other healthcare facilities. These professionals earned a mean salary of around $39,000 as of May 2014. Entry-level insurance claims and policy processing clerks had an average salary of around $39,000 as of the same month. Meanwhile, the insurance occupations of claims adjusters, appraisers, examiners and investigators (which includes medical insurance) had an average salary around $64,000, reports the BLS.

The BLS estimated employment growth of 8% for insurance industry occupations and 4% growth for insurance claims and policy processing clerks for the 2012-2022 decade. The BLS projected a 22% increase in the number of medical records and health information technicians employed during the same decade.

What Are the Requirements?

Education Requirements

The required level of education necessary to gain entry into the medical claims specialist profession depends on what your employer expects and how much prior experience you have. O*Net OnLine reported that in 2011, 65% of medical records and health information technicians had completed a high school education, 21% had completed some college and 10% had earned an associate degree. Insurance claims clerks were comparable, with 54% holding a high school diploma or the equivalent, 38% having some college experience and 5% holding an associate degree. Higher level insurance claims professionals, such as adjusters and examiners, typically had more education, with 35% holding a bachelor's degree and 32% having completed some college coursework, according to O*Net.

Some education options specifically tailored to prospective medical claims specialists include 1-year certificate and 2-year associate degree programs in health information technology or a similar field. In these programs, students typically complete coursework in medical terminology and anatomy to become familiar with the language and diagnoses seen in medical records. Courses in medical coding, billing, insurance reimbursement and computers are also included. In addition, you may qualify for a position in medical claims if you have a high school education, several years of medical coding or billing experience and professional certification.

Essential Career Skills

Because medical claims specialists interact with medical professionals, insurance companies, government agencies, patients and others when seeking claims information, they must have excellent communication skills. They must also be able to maintain a calm demeanor when speaking with customers in person or over the phone, which may be particularly difficult if the claimant is dissatisfied or irate. In this career, you work extensively with computer database systems, coding programs and other computer software, so having up-to-date skills in medical records and insurance technology is essential. Medical claims specialists review medical records for accuracy and completeness, which requires attention to detail and efficiency.

Job Postings from Real Employers

Medical claims specialist positions often require familiarity with government and private insurance reimbursement, as well as medical billing and coding. Employers typically seek candidates with a combination of relevant industry experience and education, often totaling the equivalent of three or more years. The following job postings from CareerBuilder.com and Monster.com were available during June 2012:

  • A Texas radiology practice advertised for an insurance specialist to settle payments with external insurance companies. The position required knowledge of coding, billing and a variety of medical insurance plans and providers.
  • An Ohio medical supply company looked for a medical billing claims specialist to resolve denied claims, provide information to insurance companies, collect payments from patients and fix problems with previously billed claims.
  • A healthcare organization in Indiana wanted a medical claims specialist with experience in accounts receivable, electronic billing procedures and Medicaid claims.
  • A health insurance provider in San Francisco sought a senior claims specialist to review and process claims. Additional duties included coordinating benefits and keeping records of reimbursement collection.

How to Maximize Your Skills

Some employers expect applicants to have familiarity with medical coding, insurance claims, billing and reimbursement, so gaining work experience in these areas can help you maximize your skills as a medical claims specialist. Professional certifications in coding specialties, health information management and insurance reimbursement are also available through several organizations; earning certification can help you demonstrate proficiency in these areas.

For example, the Certifying Board of the American Medical Billing Association offers a Certified Medical Reimbursement Specialist credential, with a qualifying exam that assesses a candidate's knowledge of medical claims topics. Medical coding certifications, including the Certified Professional Coder designation, are available through the American Academy of Professional Coders.

Other Careers to Consider

If you want to work in a medical setting immediately after high school and would like a job that involves some patient care, you could enter the field as a medical assistant. While a high school education and some on-the-job training is often sufficient, some employers want applicants who have completed a 1- or 2-year postsecondary program in medical assisting. Additionally, professional certification is a voluntary means of demonstrating competency. Although the BLS reported low average salaries for medical assisting positions (about $30,000 per year as of May 2011), excellent job growth is predicted from 2010-2020, with a 31% expected increase in employment. This career can be a stepping-stone to other healthcare industry positions.

If you're looking for a position with higher pay and more responsibility than what a medical claims specialist position offers, think about becoming a health information manager. This career involves overseeing the accuracy, security and maintenance of the entire patient records system for a hospital, medical practice or other healthcare facility. You'll need several years of experience, in addition to education, to earn a position as a health information manager. O*Net Online reported that 52% of these professionals held bachelor's degrees and 41% held master's degrees, while 3% had associate degrees in 2011. The number of employed health information managers was projected to grow 22% between 2010 and 2020, reports the BLS. As of 2011, these professionals had an average salary of around $96,000.

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