A medical claims analyst processes patient health-care claims for a private insurance company or a government agency. He or she has been trained to interpret medical billing codes and terminology in order to fully comprehend the paperwork submitted health care providers. Based on policy guidelines, diagnoses, and services provided at the hospital, the medical claims analyst must decide whether to accept or deny coverage for patients. To be a successful analyst, one must be extremely detail-oriented and possess excellent communication and computer skills.
People buy health insurance to cover the majority of their expenses in the event that they need to visit the hospital or a doctor’s office. When a patient receives diagnostic tests and treatment, the doctor sends the patient’s medical records to a billing specialist, who codes the information and submits it to the insurance company. To categorize illnesses, diagnoses, and treatments in a standardized chart, medical billing experts use a specialized type of coding procedure. For careful processing, the coded information is relayed to a medical claims analyst at the patient’s insurance company.
When the analyst receives information, he or she carefully reads through charts to gain a thorough understanding of the patient’s hospitalization. The analyst looks up the patient’s insurance policy, sees if it covers the services, and then processes the claim. The analyst determines whether a visit is required and whether the treatment received is covered the policy details. In terms of patient confidentiality, proper billing procedures, and reimbursement techniques, he or she must strictly adhere to legal and company standards.
In general, communication and technical skills are required to perform the job. A medical claims analyst typically receives information via e-mail and enters and manipulates claims data using specialized software programs. To clarify information, he or she frequently speaks with medical billing specialists over the phone and via e-mail correspondence.
The education and training needed to work as a medical claims analyst varies region and company. Analysts with an associate’s degree in health information technology from an accredited community college are preferred most employers. Applicants for medical claims analyst positions at some large companies must have a bachelor’s degree in nursing, pharmacy, or business administration. New analysts typically spend several weeks in training at their places of employment, under the supervision of experienced professionals, in addition to completing school programs.
Once a new analyst has gotten a feel for the job, he or she is usually given small claims to process that supervisors deem manageable. With time and experience, the analyst will be able to work more independently and on more difficult tasks. Many medical claims analysts who excel at their jobs for a long time have the opportunity to lead entire claims departments at their employers.