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Medical Claims Specialist: An Overview

By DeVry University

The information presented here is true and accurate as of the date of publication. DeVry’s programmatic offerings and their accreditations are subject to change. Please refer to the current academic catalog for details.

 

April 1, 2024
7 min read

In the healthcare revenue cycle, where providers and facilities are reimbursed by insurance companies and government-sponsored plans like Medicare, insurance claims compile all of the details of a patient encounter. This could be anything from a prescription refill to a major surgery, and all the diagnostic and treatment services that go along with it. A medical claims specialist plays an important administrative role in the healthcare industry, ensuring that these medical claims are legitimate, completed accurately and eligible for reimbursement under a patient’s insurance coverage.

In this article, we will define the role of the medical claims specialist and describe their day-to-day responsibilities. We’ll also discuss the skills and education you’ll need to prepare to enter this career. 

What Is a Medical Claims Specialist?

Similar to an insurance claims specialist, a medical claims specialist is a health information management professional. Medical claims specialists typically work for large insurance companies or government agencies. Often acting as a kind of gatekeeper between healthcare providers and payers, they determine if medical procedures are covered under patient policies and review details of insurance claims that have been submitted for reimbursement.

Medical Claims Specialist Responsibilities

Focusing on highly detailed information, the medical claims specialist carefully examines patient records and information, and makes determinations as to the eligibility, legitimacy and accuracy of medical claims. Their regular duties may include:

  • Examining claims to determine whether the applicable patient has medical insurance and is eligible to receive benefits.

  • Reviewing provisions of the patient’s insurance policy to determine the type and amounts of coverage the patient has.

  • Examining claims information, which typically includes procedure and diagnosis codes for inpatient or outpatient procedures, the identities of physicians and facilities and other claim details.

  • Contacting care providers and patients to clarify information related to medical claims.

  • Accepting or rejecting documentation associated with claims and initiating the denial or payment process.

  • Negotiating claim settlements and making recommendations for legal action when settlements are considered to be non-negotiable.

  • Ensuring that confidentiality is maintained throughout the life of a claim with respect to patients’ protected health information and in compliance with guidelines like the HIPAA Privacy Rule.

In addition to these everyday responsibilities, medical claims specialists are required to adhere to all company policies and federal and state insurance regulations, and to engage in continuing professional education and training opportunities when they can. 

Claims Specialists’ Skills

Medical claims specialists work in a field that demands both technical and workplace skills.

Technical skills like data entry and knowledge of healthcare policy and regulations enable them to evaluate claims and patients’ insurance policies effectively:

  • Data entry skills

     In this area, medical claims specialists benefit from a knowledge of medical terminology and medical billing codes as they examine claims information. Some knowledge of specialized software systems may also be required.

  • Knowledge of health regulations

    Adherence to state and federal regulations, and privacy rules like HIPAA require knowledge of these guidelines, and a skill for knowing how they are applied and when.

Workplace skills, like strong interpersonal capabilities, allow them to communicate and collaborate effectively:

  • Interpersonal skills

    Communication skills enable medical claims specialists to interface effectively with medical professionals, patients and other stakeholders while maintaining high standards in customer service. 

  • Time management

    Knowing how to manage a schedule and prioritize important tasks helps these healthcare professionals maintain order when faced with a heavy workload.

  • Attention to detail

    Details of diagnostics, procedures, and the limitations of patients’ insurance coverage have a major impact on the way claims are processed. Being detail-oriented with the ability to multi-task effectively are important attributes for medical claims specialists.

  • Analytical abilities

    The ability to evaluate the raw information contained in a insurance claim is an important skill for anyone aspiring to become a medical or insurance claim specialist to possess.

Education Requirements

The specific education requirements for a medical claims specialist role will likely vary from one employer to another, but obtaining the appropriate education should be the first step in your journey.

According to the Bureau of Labor Statistics (BLS), medical records specialists, a career that medical claims specialist is related to, you’ll need at least a high school diploma or equivalent, though an associate or bachelor’s degree may be required by some employers. Industry certifications may also be required.

The BLS states that certificate and associate programs offered by some colleges that include courses in medical terminology, coding classification systems and data standards can be useful for those preparing to pursue a career in this field.

At DeVry, we can help you get started with our online Undergraduate Medical Billing and Coding Certificate programs. Featuring what we call our Digital Health Core, these 100% online programs includes coursework in medical terminology, health insurance and reimbursement, International Classification of Disease (ICD) coding, patient privacy, compliance and ethics, and other relevant topics that can help you develop the skills to prepare to pursue a number of important roles in healthcare. Graduates of these programs may consider roles such as Medical Records and Health Information Technician, Medical Biller, Insurance Claims Specialist and others.

In occupations related to medical billing coding and health information technology, certifications verify specific skills. Employers may require job candidates to hold certifications at the time they’re hired or earn them shortly after. At DeVry, our Medical Billing and Coding Certificate program includes material addressed in the Certified Professional Coder (CPC®) certification exam in the form of a Coding Practicum and Review (CPC® Exam) course. Our Medical Billing and Coding – Health Information Coding certificate program includes material addressed in the Certified Coding Specialist (CCS®) exam in the form of a CCS® Review (CCS® Exam) course. DeVry students who earn an 85% or higher in these courses can earn a voucher for the CPC® and CCS® exams, respectively. The voucher code is valid for 60 days. 

If you wish to advance your education, both the Undergraduate Certificate in Medical Billing and Coding and our Undergraduate Certificate in Medical Billing and Coding – Health Information Coding program stacks into our Associate Degree in Health Information Technology,1 allowing you to apply eligible credits from your certificate program into a qualifying higher level degree.

DeVry’s Associate Degree in Health Information Technology is designed for today’s digital health careers and allows you to select from 4 career-focused degree specializations: Analytics, General Health Services, Health Information, or IT and Cyber Security. Want to go even further? Eligible courses from this associate degree stack into our Bachelor of Science in Technical Management with a Specialization in Health Information Management1, where you will learn administration skills, project management, leadership skills and how to exercise judgement in situations related to cost and benefit within a healthcare environment. 

Earn Your Undergraduate Certificate in Medical Billing and Coding at DeVry

Prepare to pursue a career in the medical billing and coding field with our flexible, 100% online Undergraduate Certificate in Medical Billing and Coding programs.

You can earn your Undergraduate Certificate in Medical Billing and Coding in as little as 10 months on an accelerated schedule, or choose a normal schedule and complete your program in 1 year and 2 months.2 This online certificate program can help you begin your career journey by helping you gain the range of specialized knowledge and skills needed to work in the field and prepare to pursue the CPC® certification exam.

2Normal schedule includes breaks and assumes 2 semesters of year-round, full-time enrollment in 6-13 credit hours a semester per 12 month period. Accelerated schedule does not include breaks and assumes 3 semesters of year-round, full-time enrollment in 6-13 credit hours a semester per 12 month period.

You can also earn your Undergraduate Certificate in Medical Billing and Coding – Health Information Coding (HIC) in as little as 1 year and 2 months on an accelerated schedule, or in 1 year and 6 months on a normal schedule.3 This online certificate program involves more detailed instruction on various medical billing and coding concepts and helps prepare you to pursue the CCS® certification exam.

3Normal schedule includes breaks and assumes 2 semesters of year-round, full-time enrollment in 3-13 credit hours a semester per 12 month period. Accelerated schedule does not include breaks and assumes 3 semesters of year-round, full-time enrollment in 3-13 credit hours a semester per 12 month period.

And when you study with DeVry, our shared commitment to your success comes with access to Career Services support to help with your job search and building your resume. Classes start soon. Let’s talk about getting you started in the program that best suits your goals.

Find Out More

1For the MBC certificate program, eligible credits apply to our Associate of Applied Science in Health Information Technology. For the MBC-HIC undergraduate certificate program, eligible credits apply to our Associate of Applied Science in Health Information Technology. For the Associate Degree in Health Information Technology program, eligible credits apply our Bachelor of Science in Technical Management with a Specialization in Health Information Management. Program availability varies by location.

2Normal schedule includes breaks and assumes 2 semesters of year-round, full-time enrollment in 6-13 credit hours a semester per 12 month period. Accelerated schedule does not include breaks and assumes 3 semesters of year-round, full-time enrollment in 6-13 credit hours a semester per 12 month period.

3Normal schedule includes breaks and assumes 2 semesters of year-round, full-time enrollment in 3-13 credit hours a semester per 12 month period. Accelerated schedule does not include breaks and assumes 3 semesters of year-round, full-time enrollment in 3-13 credit hours a semester per 12 month period.

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In New York, DeVry University operates as DeVry College of New York. DeVry University is accredited by The Higher Learning Commission (HLC), www.hlcommission.org. The University’s Keller Graduate School of Management is included in this accreditation. DeVry is certified to operate by the State Council of Higher Education for Virginia. Arlington Campus: 1400 Crystal Dr., Ste. 120, Arlington, VA 22202. DeVry University is authorized for operation as a postsecondary educational institution by the Tennessee Higher Education Commission, www.tn.gov/thec. Lisle Campus: 4225 Naperville Rd, Suite 400, Lisle, IL 60532. Unresolved complaints may be reported to the Illinois Board of Higher Education through the online complaint system https://complaints.ibhe.org/. View DeVry University’s complaint process   https://www.devry.edu/compliance/student-complaint-procedure.html Program availability varies by location. In site-based programs, students will be required to take a substantial amount of coursework online to complete their program.


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