What does a medical claims specialist do?
A medical claims specialist is responsible for gathering and processing the information required to complete the medical insurance claims process. Typical duties include determining covered medical insurance losses, documenting medical claims actions, and resolving claims through approval or denial of documentation. In addition, you will be responsible for maintaining excellent customer service by responding to customer inquiries and following best practices. You will also be responsible for protecting company operations by maintaining the confidentiality of information.
Medical claims specialist responsibilities
Here are examples of responsibilities from real medical claims specialist resumes:
- Apply Medicare, Medicaid billing guidelines to achieve maximum reimbursement.
- Detail knowledge of medical coding; ICD-9, CPT and HCPCS codes.
- Confirm coverage and work with private payers, commercial payers, Medicaid, and Medicare for reimbursement of provide medical services.
- Research medical records, compliance requirements and explanations of benefits to resolve accounts payable for Medicare, Medicaid and commercial insurance.
- Maintain strict confidentiality/privacy of patients' protect health information in accordance with HIPAA regulations.
- Assist in educating new hires in HIPPA laws and training.
- Assist with special reports of tracking problem medical claims according to HIPPA guidelines.
- Adhere to strict HIPAA guidelines for handling and processing sensitive information within these claims.
- Review documentation, analyze reject claim data, justify CPT & HCPCS codes and pay HCFA-1500 and UB92 claims.
- Obtain and enter demographic, clinical, income information into the computer system, efforts ensure compliance with HIPAA.
- Review and resolve claim appeals according to policy guidelines.
- Review multiple radiology reports from different clinics/hospitals and diagonals them.
- Work all identify Medicaid requirement edits through the electronic billing system.
- Resubmitted correct claims and appeals to insurance companies within timely filing.
- Verify documents and coordinate health care coverage for patients, including eligibility of benefits.
Medical claims specialist skills and personality traits
We calculated that 14% of Medical Claims Specialists are proficient in Customer Service, Patients, and Medicaid. They’re also known for soft skills such as Integrity, Technical skills, and Analytical skills.
We break down the percentage of Medical Claims Specialists that have these skills listed on their resume here:
- Customer Service, 14%
Developed and taught classroom materials to assist in preparing the newly hired claims examiners/adjusters and customer service associates after training.
- Patients, 9%
Maintain strict confidentiality/privacy of patients' protected health information in accordance with HIPAA regulations.
- Medicaid, 7%
Utilized knowledge of governmental insurance Medicare, Medicaid in order to efficiently manage Medical Claims.
- Medical Billing, 6%
Managed and maintained all aspects of medical billing for inpatient/outpatient mental health facility that employed 10 Professionals.
- Phone Calls, 6%
Research claims balances using online research through insurance company portals, and telephone calls to company regarding claims status and concerns.
- Medical Terminology, 5%
Required review of medical terminology/records to determine the medical necessity / relationship of treatment.
Common skills that a medical claims specialist uses to do their job include "customer service," "patients," and "medicaid." You can find details on the most important medical claims specialist responsibilities below.
Integrity. The most essential soft skill for a medical claims specialist to carry out their responsibilities is integrity. This skill is important for the role because "health information technicians work with patient data that are required, by law, to be kept confidential." Additionally, a medical claims specialist resume shows how their duties depend on integrity: "instruct trust companies on what payments should be made on behalf of their clients regarding medical claims. "
Technical skills. Another soft skill that's essential for fulfilling medical claims specialist duties is technical skills. The role rewards competence in this skill because "health information technicians must use coding and classification software and the electronic health record (ehr) system that their healthcare organization or physician practice has adopted." According to a medical claims specialist resume, here's how medical claims specialists can utilize technical skills in their job responsibilities: "received numerous recognitions for outstanding customer service and technical excellence from high leadership. "
Analytical skills. This is an important skill for medical claims specialists to perform their duties. For an example of how medical claims specialist responsibilities depend on this skill, consider that "health information technicians must understand and follow medical records and diagnoses, and then decide how best to code them in a patient’s medical records." This excerpt from a resume also shows how vital it is to everyday roles and responsibilities of a medical claims specialist: "provide timely and accurate data entry of medical information from the paper chart into electronic medical record. ".
Detail oriented. A big part of what medical claims specialists do relies on "detail oriented." You can see how essential it is to medical claims specialist responsibilities because "health information technicians must be accurate when recording and coding patient information." Here's an example of how this skill is used from a resume that represents typical medical claims specialist tasks: "detailed knowledge of medical coding; icd-9, cpt and hcpcs codes. "
Interpersonal skills. Another crucial skill for a medical claims specialist to carry out their responsibilities is "interpersonal skills." A big part of what medical claims specialists relies on this skill, since "health information technicians need to be able to discuss patient information, discrepancies, and data requirements with other professionals such as physicians and finance personnel." How this skill relates to medical claims specialist duties can be seen in an example from a medical claims specialist resume snippet: "cited for excellence in interpersonal communications, teamwork, customer service, flexibility and reliability. "
The three companies that hire the most medical claims specialists are:
- CorVel14 medical claims specialists jobs
- ABC Supply Co8 medical claims specialists jobs
- University of Rochester7 medical claims specialists jobs
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Compare different medical claims specialists
Medical claims specialist vs. Billing representative
A billing representative assists with the overall operations of the organization's billing department. Billing representatives post payments timely on the database, update account statements, generate financial reports, release invoices, and resolve account discrepancies. They also perform client accounts reconciliation as needed, monitor account receivables, review overdated balance, and notify clients of payment updates to ensure accurate and timely billing. A billing representative must have strong analytical and communication skills to manage clients' accounts, as well as comprehensive knowledge on the accounting industry to explain the payment terms and policies of an organization to a client.
While similarities exist, there are also some differences between medical claims specialists and billing representative. For instance, medical claims specialist responsibilities require skills such as "phone calls," "epic," "medical treatment," and "excellent interpersonal." Whereas a billing representative is skilled in "cpt," "medical claims," "insurance claims," and "computer system." This is part of what separates the two careers.
Billing representatives earn the highest salaries when working in the technology industry, with an average yearly salary of $35,295. On the other hand, medical claims specialists are paid more in the government industry with an average salary of $40,426.The education levels that billing representatives earn slightly differ from medical claims specialists. In particular, billing representatives are 1.0% less likely to graduate with a Master's Degree than a medical claims specialist. Additionally, they're 0.8% less likely to earn a Doctoral Degree.Medical claims specialist vs. Health information technician
A health information technician is primarily responsible for managing and handling patient information, ensuring accuracy and confidentiality. They coordinate with various health care workers to gather patient data, laboratory results, test findings, and medical histories, encoding them in clinical databases in a timely and efficient manner. They must analyze every information to detect any inconsistencies, performing corrective measures right away. Furthermore, as a health information technician, it is essential to utilize particular software and systems when processing information, all while adhering to the hospital's policies and regulations.
While some skills are similar in these professions, other skills aren't so similar. For example, resumes show us that medical claims specialist responsibilities requires skills like "medical billing," "epic," "eob," and "medical treatment." But a health information technician might use other skills in their typical duties, such as, "patient care," "office equipment," "transcription," and "rehabilitation."
Health information technicians may earn a lower salary than medical claims specialists, but health information technicians earn the most pay in the government industry with an average salary of $35,705. On the other hand, medical claims specialists receive higher pay in the government industry, where they earn an average salary of $40,426.Average education levels between the two professions vary. Health information technicians tend to reach similar levels of education than medical claims specialists. In fact, they're 0.2% less likely to graduate with a Master's Degree and 0.8% less likely to earn a Doctoral Degree.Medical claims specialist vs. Medical biller coder
A medical biller coder is responsible for handling the billing processes and insurance within a hospital, clinic, or similar facility. They must gather patient information and records to analyze and translate them into codes according to the insurance and medical guidelines. Moreover, it is crucial to verify all patient forms and ensure their accuracy as it will serve as a basis on essential documents and medical record-keeping. There may also be instances where a medical biller coder must devise payment plans for patients, communicate with families and guardians, and coordinate with physicians.
There are many key differences between these two careers, including some of the skills required to perform responsibilities within each role. For example, a medical claims specialist is likely to be skilled in "phone calls," "epic," "medical treatment," and "excellent interpersonal," while a typical medical biller coder is skilled in "medicare," "physical therapy," "emr," and "radiology."
Medical biller coders earn the highest salary when working in the professional industry, where they receive an average salary of $39,875. Comparatively, medical claims specialists have the highest earning potential in the government industry, with an average salary of $40,426.When it comes to education, medical biller coders tend to earn similar degree levels compared to medical claims specialists. In fact, they're 1.9% less likely to earn a Master's Degree, and 0.8% less likely to graduate with a Doctoral Degree.Medical claims specialist vs. Medical records clerk
Medical records clerks are employees in hospitals or clinics who manage office records. They are in charge of creating, updating, and filing patient-related medical records and other related documents. They ensure that all documents are correctly filled out and labeled before storing them safely in their respective storage areas. They may also be in charge of digitizing forms for easier access to files and back up purposes. They ensure that medical records are exact and updated. Medical records clerks should be organized and must always be on top of all tasks related to patient or medical records.
Types of medical claims specialist
Updated January 8, 2025
