A medical claims analyst processes patient healthcare claims, interpreting medical billing codes and determining coverage based on policy guidelines. Strong communication and computer skills are essential, and education requirements vary. Analysts can advance to become managers of claims departments.
A medical claims analyst works for a private insurance company or government organization to process patient health care claims. He or she is trained to interpret the codes and terminology commonly used in medical billing to fully understand the paperwork that is submitted by healthcare providers. The medical claims analyst must determine whether to accept or deny coverage for patients based on policy guidelines, diagnoses, and services provided at the hospital. To be a successful analyst, an individual must be very detail oriented and have strong communication and computer skills.
People buy health insurance policies to cover most experiences if they need to visit the hospital or doctor’s office. When an individual actually receives diagnostic tests and treatment, the physician passes their medical records on to a billing specialist to encode the information and send it to the insurance company. Medical billing specialists rely on a specialized type of coding procedure to categorize illnesses, diagnoses and treatments into a standardized chart. The encoded information is transmitted to a medical claims analyst at the patient’s insurance company for careful processing.
When the analyst receives information, he or she carefully reads the graphs to understand everything about the patient’s hospital visit. The analyst retrieves the policy from the patient, determines whether it covers the services provided, and processes the claim accordingly. The analyst decides whether a visit was necessary and whether the policy details actually cover the treatment received. He or she must strictly adhere to legal and company standards regarding patient confidentiality, proper billing procedures and reimbursement techniques.
Technical and communication skills are often essential to getting the job done. A medical claims analyst typically receives information via email and uses specialized software programs to enter and manipulate claim data. He or she frequently talks with medical billing specialists over the phone and via email to clarify information.
Education and training requirements to become a medical claims analyst vary between regions and companies. Most employers prefer to hire analysts who have completed degree programs in health information technology at accredited community colleges. Some large companies require applicants for medical claims analyst positions to have a bachelor’s degree in nursing, pharmacy, or business administration. In addition to completing school programs, new analysts often spend several weeks in on-the-job training under the supervision of experienced professionals.
Once a new analyst is comfortable with the job’s tasks, he or she can usually process minor complaints that supervisors find relatively easy to handle. With proven experience and skills, the analyst can begin to work more independently and take on more difficult assignments. Many medical claims analysts who have performed well in their jobs for many years have the opportunity to become managers of entire claims departments within their companies.
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