How to Become a Health and Medical Claims Specialist

What is a Health Claims Specialist?

A health (or medical) claims specialist is a professional who is trained and knowledgeable in processing hospital bills, medical insurance claims and sorting out any issues that may arise in billing. Another term for a health claims specialist is a medical billing and coding specialist. The job of a health claims specialist revolves around fool-proof documentation, ensuring legal compliance and making sure that health providers get compensated for their services.

If you are good with paperwork, thorough with documentation, possess an appreciation for detail and desire to have an office based career in the expanding health care industry then becoming a health claims specialist may be the ideal career direction for you. Not only will you enjoy your work life but will also welcome expansion opportunities.

What Does a Health Claims Specialists Do?

A health claims specialist often spends much of their working day on the telephone dealing with both inbound and outbound calls and using a computer. Overall their job revolves around the tasks involved in gathering and processing the information needed to prepare and submit documentation that is used to obtain reimbursement for healthcare services that have been provided to patients.

Organizations often assign these professionals a number of patient files to work on each day. If there are no designated medical coders in the organization, the health claim specialist may be responsible for adding the appropriate codes to each file to identify what medical diagnoses were made and what treatments were provided to the patient. There are tens of thousands of possible codes, and a health claims specialist may use two computer screens at once to help them perform this task, one to show the list of codes, and their use, and one for the patient file that they are updating.

Once the codes have been entered correctly, the next task of a health claims specialist is to prepare and submit the correct package of documents to create an insurance claim with Medicaid, Medicare, or a private insurance firm. This involves filling out the appropriate forms and finding and attaching all the relevant and required supporting documents. Where there are gaps in the information that is needed, or the information is unclear or ambiguous, the healthcare claims specialist may need to contact a physician, the patient, other colleagues such as clinical documentation specialists or medical coders, or insurance providers to obtain or clarify the information.

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The health claims specialist also updates the patient’s records to show a claim has been made and may also need to update other logs and records so that their organization can maintain a high-level overview of claims and billing amounts.

Healthcare insurance claims are sometimes rejected and often generate queries and disputes about responsibility for payment between healthcare providers, insurance companies, and patients which must be resolved before reimbursement is provided. Health claims specialists follow up and resolve any queries, re-submit any rejected claims, and help solve outstanding disputes.

Where Does a Health Claims Specialist Work?

A health claims specialist typically works in an office or call center environment. These may be located within any medical agency including hospitals, physician’s offices, nursing homes, and outpatient centers. In addition, you find health claims specialists working in health maintenance organizations (HMOs), insurance companies, government agencies and medical billing companies.

As nearly all the work of a health claims specialist can be performed with just a computer and a telephone, some of these professionals may work from home.

What are the Requirements to Become Health Claims Specialist?

Educational Requirements

It is possible to obtain an entry-level role as a health claims specialist with a high school diploma. Applicants may increase their chances of obtaining such a role by taking relevant high school classes such as math, biology, and computer science. On the job training may be provided by the employer and is likely to cover topics such as medical terminology, insurance forms and procedures, medical and procedural coding, how to use organizational IT systems and software, and organizational guidelines and procedures for processing medical claims.

There are many educational institutions that offer accredited certificates in medical billing and coding. These programs may increase the chances of an applicant securing a better role. Course lengths, admission criteria, and content vary by institution. A typical program may require only a high school diploma for admission, be offered fully online, and may take up to a year to complete. The curriculum focuses on building the student’s knowledge of the most common coding manuals and helps prepare them to sit for professional certification examinations.

Although neither an associate degree nor a bachelor’s degree is mandatory for a career as a health claims specialist, accredited certificate programs may offer credits towards an associate (AAS) degree in health information technology (HIT) or a bachelor’s degree (BS) in health information management (HIM). Both would be relevant for the role.

Certification Requirements

Health claims specialists typically do not require professional certification in order to find employment. However, many health claim specialists do seek professional certification to evidence their skills and render them more attractive to potential employers.

Several different certification options are available. Eligibility to obtain certification varies by institution and the type of certification. Eligibility criteria may include completion of an accredited program of study, evidence of a certain period of experience, or simply to achieve a pass on a specific examination.

One popular option is to take the Certified Professional Coder examination offered by the American Academy of Professional Coders (AAPC). The CPC examination is an open-book examination that consists of 150 multiple-choice questions regarding the correct application of CPT, HCPCS-II, and ICD-10-CM.

What Does It Take to Become a Health Claims Specialist?

Medical Coding Knowledge

Health claims specialists need expert knowledge and understanding of medical coding. Current code systems include the International Classification of Diseases (ICD-10-CM), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS-II).

ICD-10-CM is the 10th revision of the main medical classification list compiled by the World Health Organization (WHO). It contains codes for diseases, symptoms, abnormal findings, complaints, social circumstances, and other causes of injury and includes more than 68,000 codes. In addition, there are approximately 10,000 CPT codes. These are published by the American Medical Association and are intended to provide a uniform set of ways to describe medical, surgical, and diagnostic services.

HCPCS-II is a code set that is used for medical supplies, durable medical goods, and non-physician services such as ambulances, prosthetics, orthotics and so forth. Health claims specialists are not expected to memorize all these codes, although they often commit the more common codes to memory, but they are required to understand where to find them, how and when to use them correctly, and when to modify them. Incorrect coding may lead to many undesirable outcomes including inappropriate or unsafe treatment of patients and may prevent the organization from obtaining the correct amount of reimbursement from patients or insurance companies.

IT Literate

Much of the work of a health claims specialist is completed using a computer and may involve the use of two or more monitors. Health claims specialists must be able to navigate the computer software required to perform their roles effectively.

Data Handling and Entry Skills

Fast and accurate data entry skills are a key requirement of the role as small mistakes may result in rejected claims, queries, and disputes.

Communication Skills

Health claims specialists frequently work in call center environments and spend a sizeable proportion of their time on the telephone with patients, insurance companies, government agencies, and healthcare professionals. Their verbal communication skills must be top-notch.


Individuals who are naturally detail-focused are good candidates for this career as ensuring accuracy and completeness across a range of forms and electronic paperwork is a core requirement of the job.

Organization Skills

Health claims specialists need to keep track of the status of claims and queries and may also need to maintain accurate records of payment plans, delinquent bills, and payments received. Good organizational skills will help them to achieve these tasks efficiently.

Policy and Procedure Knowledge

Health claims specialists need up-to-date knowledge of hospital policies, claims payment regulations, and insurance company procedures.

Maintain Confidentiality

Health claims specialists are exposed to sensitive personal information and need to discuss aspects of that information with others in order to do their jobs. It is essential they understand the need for privacy and security of personal data and act accordingly.

Familiarity with Medical Terminology

Health claims specialists should be familiar with medical terminology so that they can interpret the information they are processing correctly.


Health claims specialists may come under pressure to maximize financial benefit to their organization. To ensure accurate recording and fair reimbursement, these professionals need to be able to resist any such pressure and act with integrity.

What is the Average Salary of a Health Claims Specialist?

The Bureau of Labor Statistics (BLS) reports the median salary for a medical records and health information technician was $38,040 in May 2016. Records technicians working in professional and scientific services were earning the most while those working in physician’s offices were earning the least. suggests that a health claims specialist earns an average of $16.47 per hour, as of March 2018.

What is the Job Outlook for Health Claims Specialists?

The Bureau of Labor Statistics indicates the employment of medical record and health information technicians is likely to grow by 13% between 2016 and 2026. This growth translates to roughly 27,800 new jobs. This is faster than the average for all occupations but slightly lower than the average for healthcare occupations overall, which is projected to grow 18% from 2016 to 2026

The overall growth in demand for healthcare professionals is being driven by the aging U.S. population who require more medical services. The delivery of medical services in the USA relies upon a complex network of insurance providers, patients, healthcare organizations, and government agencies. The need for health claims specialists to navigate this complex network to ensure fair reimbursement for medical services rendered continues to grow.

Furthermore, due to the increase in medical insurance options for the public and an aging population, the demand for health claims specialists is on the rise. Another contributing factor is the increased awareness of preventative medicine as people have realized it is important to plan ahead and take precautionary measures when it comes to their health. All these factors have increased the need for medical tests, treatments, procedures and paperwork which in turn have increased the demand for medical claims specialists.

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