Medical Claims Examiner | Duties, Training and Schools

What is a Medical Claims Examiner?

A medical claims examiner works in the insurance field to ensure that medical services providers submit insurance claims correctly and in a timely manner.

In other words, a career as a medical claims examiner means investigating insurance claims, confirming that the billed costs are accurate, and that the treatments and procedures that a patient receives are commensurate with their diagnosis. Though medical claims examiners aren’t trained medical practitioners, they must possess an intimate knowledge of medical procedures in order to fulfill the duties of their job.

What Does a Medical Claims Examiner Do?

The central role of a medical claims examiner is to protect insurance companies from financial losses. To provide their employers with that protection, medical claims examiners investigate insurance claims to ensure that the amounts billed to insurance for things like surgery, medical tests, rehabilitative services, and so forth, are both accurate and appropriate for the type of services rendered.

For example, if a person has surgery on their knee, a medical claims examiner would evaluate every claim to insurance for that surgery. This would include claims for emergency services like an emergency room visit, evaluative procedures like X-rays or an MRI, surgical procedures, support services during surgery like anesthesia, as well as post-surgery recovery services like physical therapy.

But medical claims examiners don’t just take a look at the claims submitted on behalf of patients. Instead, they also review the work of other insurance claims workers to determine accuracy. For example, if an insurance claims adjuster submits a claim on behalf of a client for a prescription, a medical claims examiner might review the adjuster’s paperwork to look for any errors or inaccuracies. This includes double-checking claims to ensure that they are submitted in a manner that follows the insurance company’s guidelines.

Related Reading: How to Become a Medical Biller

Another primary role of medical claims examiners is to investigate complex cases in which a major payout to a large group of individuals is possible, like in situations in which a group of patients claim injury due to a particular medical procedure or drug therapy. Likewise, medical claims examiners focus a lot of their attention on insurance claims of a questionable nature. More specifically, they work to determine whether or not the insurance claim is appropriate and necessary. If they determine that the claim is not appropriate, they will recommend that the insurer refuse payment.

Furthermore, medical claims examiners often work to settle cases. For example, if a claim is submitted and is found to have merit, the examiner will process the claim and recommend payment. However, if they determine that the claim isn’t appropriate as noted above, the case would then be referred to an insurance investigator for deeper analysis.

A final aspect of this job is of an accounting nature. Since examiners are responsible for processing claims to be paid out, they play an important role in preserving the insurance company’s cash reserves. To protect the insurer’s bottom line, examiners often study the types of claims being made, make recommendations regarding the types of payouts made, as well as examine applications for coverage that might pose a lot of risk for the company, like insuring a person with terminal cancer.

What Do You Learn in a Medical Claims Examiner Training Program?

To begin a career as a medical claims examiner, one must first learn certain knowledge and skills that will help them execute the duties of the job. Common learning targets include, but are not limited to, the following:

Medical terminology – During their training, medical claims examiners are schooled in various medical terms, including common medical terminology that must be understood in order to evaluate medical claims.
Research protocols – When studying to become a medical claims examiner, students develop skills necessary to conduct research, including building analytical and problem solving skills.
Data entry – Much of a medical claims examiner’s job is investigating claims and conducting research. As such, they must be able to record data accurately and efficiently, often into an insurance company’s proprietary software.
10-key computer skills – Workers in this field have to enter a lot of numerical data, which necessitates being proficient in 10-key computer data entry.
Data analysis – Not only do medical claims examiners need to be able to collect data, but they must also possess the ability to analyze data, interpret data, and make educated assumptions about what the data is telling them.
Privacy laws – Various state and federal laws ensure a patient’s privacy. Students in a medical claims examiner training program must be intimately familiar with such laws.
Insurance procedures – Medical claims examiner students learn different procedures for insurance claims, including how to review them, reasons for denying a claim, and how to process approved claims.
Customer service – Though medical claims examiners don’t often have direct contact with patients, training programs nevertheless offer instruction in how to interact with customers and colleagues in a positive manner.
Medical billing procedures – Future medical claims examiners learn about the medical billing process, including the typical cost of procedures, terminology used in medical billing, and electronic medical billing practices.

What are the Requirements to Become a Medical Claims Examiner?

Educational Requirements

Typically, most medical claims examiner positions do not have formal post-secondary education requirements. That is, most jobs in this field are open to individuals that have a high school diploma or GED and do not require a bachelor’s degree, master’s degree, or doctorate to start work.

Though some companies might offer in-house training programs for applicants for medical claims examiner positions, most often that training is done prior to starting work. Certificate programs for medical claims examiners are abundant, and offer students a means of acquiring the necessary knowledge and skills to be effective in their position as a claims examiner.

Typical certificate programs last less than a year – and in some cases just a few months – and concentrate on topics like medical terminology, ethics, insurance policies, healthcare laws, and other topics related to this line of work. The essential goal of these programs is to provide students with a solid introductory knowledge base such that they can begin work in medical claims examining. As mentioned earlier, on-the-job training is often provided to further workers’ understanding of how to do their job well.

Certification Requirements

Though certification in this field is not always required, it is typically a good idea to be certified, simply because it demonstrates to employers that one has a willingness and a drive to further their skills and equip themselves with advanced knowledge of the medical and insurance fields.

Certification requirements can vary widely from one state to the next (and even one employer to the next), so it’s prudent to check with the appropriate governing body in the state in which one will be employed to determine the specific requirements that must be met for certification. One popular certifying body is the American Institute for Chartered Property Casualty Underwriters, which offers certification as a medical claims examiner. One must take a specified set of classes and pass an exam to be certified.

Can a Medical Claims Examiner Work from Home?

Typically, medical claims examiners work for insurance companies or large medical organizations, like an HMO. However, these workers are not always required to work on-site. Instead, some medical claims examiners can conduct much of the business of their job from home, provided that they have internet access and a computer. Medical claims investigations often require a lot of communication with various stakeholders, so having a home phone or reliable mobile phone coverage is a must in order to work from home.

What Does It Take to Become a Medical Claims Examiner?

To be a medical claims examiner, one must possess particular skills and qualities in order to be successful. These include:

Knowledge of insurance standards guidelines – Medical claims examiners should be familiar with insurance standards that guide claims work, such as the types of treatments that are commonly used for particular illnesses.
Understanding of insurance practices – Claims examiners are required to have a deep understanding of insurance practices, including company policies and procedures that govern payouts and claims denials.
Written communication skills – This career requires workers to be able to communicate effectively in written form, including writing detailed reports that are accurate.
Basic medical knowledge – Claims examiners must be able to understand basic medical terms and understand common medical procedures.
Understanding of human behavior – It’s helpful for claims examiners to understand how and why people behave the way that they do as it often assists them in understanding the factors involved in each claim they process.
Computer skills – Medical claims examiners must manage a lot of electronic data as well as record data that they collect. As a result, being technologically savvy is a must.
Analytical skills – Workers in this field must be able to think critically and analyze information quickly and easily to determine the accuracy and worthiness of claims.
Detail-oriented – It can be easy to get lost in the details in this profession. With so much information to sift through, being precise and detail-oriented is a definite plus.
Integrity – Claims examiners are tasked with determining if and when a claim is approved. Since lives might hang in the balance, being a person of great integrity is necessary.

How Much Does a Medical Claims Examiner Make?

As of May 2017, the Bureau of Labor Statistics estimated that the average yearly salary for a medical claims examiner was $64,900. The pay range for this position varies widely, though, from a high of nearly $100,000 per year to a low of around $38,900 per year.

The compensation one can expect as a medical claims examiner hinges upon factors like level of education and years of experience. For example, an examiner with 15 years of experience can command a higher salary than one with less than one year on the job. Likewise, an examiner with a college degree and/or continuing education credits under their belt is more likely to earn a higher salary than a worker with just a high school diploma and some on-the-job training.

What is the Job Outlook for Medical Claims Examiners?

According to the Bureau of Labor Statistics, the job outlook for workers in this field is not good. In fact, jobs for claims adjusters, appraisers, examiners, and investigators as a whole are predicted by the BLS to decline by one percent through 2026.

The chief reason why jobs as medical claims examiners are expected to decline is due to technology. As automation continues to grow in popularity, the need for human adjusters will continue to be reduced. With fewer positions open, competition for the remaining jobs will surely rise.

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How to Become a Medical Claims Examiner