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What does a Medical Insurance Specialist do?

Malcolm Tatum
Updated: Mar 02, 2024

Medical insurance specialists are professionals that handle a number of essential tasks around doctors' offices and other medical facilities. The typical medical insurance specialist will work closely with patients, insurance companies, and other staff in the office to ensure that all matters regarding charges, claims, and payments are handled in an efficient manner. The specialist is usually proficient with health plans available in the area, how to read and prepare medical bills, and how to determine the proper health care costs associated with any procedure that is performed. Here are a few examples of the duties that specialists of this type are likely to perform on a daily basis.

One of the most important tasks of any medical insurance specialist is to collect and assess the insurance coverage currently held by patients. Going over the coverage with patients makes it possible to determine if any co-pays are due at the time services are rendered or if the insurance provider will cover all costs. This important task helps to ensure that no time is wasted filing claims that will not benefit the patient or the health care provider, and that everyone knows exactly when and how payment can be expected.

The medical insurance specialist also is involved in the review of charges and submitting claims to insurance providers. As part of this process, the specialist also works with billing personnel to ensure that the invoices for services rendered are complete and billed at the correct rates. The data can then be used to prepare insurance claims on behalf of the patient and submit them directly to the insurance provider. When completed accurately, the insurance provider can respond quickly, either rejecting the claim or remitting payment to the health care provider.

It is not unusual for a medical insurance specialist to also have a working knowledge of medical coding. The universal coding is used by most insurance companies to categorize and evaluate submitted claims. Knowing how to code the claims properly helps to expedite the processing and in turn makes it possible for the health care facility to be compensated in a timely manner.

Maintaining accurate and timely information in each patient’s medical records is also an important function of the medical insurance specialist. Doing so ensures that data is on hand to justify any claims submitted to insurance providers as well as creating a platform to document any related correspondence from the providers. Many jurisdictions require this type of detail as a matter of basic standards for health care providers, and as a means of complying with provisions found in local laws.

A competent medical insurance specialist may work in a number of different health care environments. In addition to a doctor’s office, the specialist may work in clinics, hospitals, and nursing homes. There are also health care jobs of this type found in public health agencies and private healthcare associations. Essentially, any environment where there is a need to understand health insurance plans and the various types of insurance issues that can arise, the services of a medical insurance specialist are likely to be required.

Practical Adult Insights is dedicated to providing accurate and trustworthy information. We carefully select reputable sources and employ a rigorous fact-checking process to maintain the highest standards. To learn more about our commitment to accuracy, read our editorial process.
Malcolm Tatum
By Malcolm Tatum
Malcolm Tatum, a former teleconferencing industry professional, followed his passion for trivia, research, and writing to become a full-time freelance writer. He has contributed articles to a variety of print and online publications, including Practical Adult Insights, and his work has also been featured in poetry collections, devotional anthologies, and newspapers. When not writing, Malcolm enjoys collecting vinyl records, following minor league baseball, and cycling.
Discussion Comments
By icecream17 — On Apr 07, 2011

I have considered becoming a medical insurance specialist -- I've worked in medical transcription for years, so I know some about the industry -- but it seems like the job really takes a lot of work. I mean, I'm not looking for a walk in the park, but it took me long enough to learn medical coding for my transcription work, I can't imagine learning a whole new system about payments as well. What do you all think?

Does anybody reading this work in medical insurance, can you give me a little better feel for the day to day in this job?

By subway11 — On Apr 06, 2011

Does anyone know if I could possibly go from being a home insurance specialist to a medical insurance specialist? I have been working in home insurance for a few years, but I've heard that medical insurance specialists can make a lot more, at least in my region. Does anyone have any tips for making this career move?

By GreenWeaver — On Apr 05, 2011

I wonder how difficult it will be for the health insurance specialists to perform their jobs with all of the changes in the health care bill.

This really affects medical insurance coverage for all Americans because now it will include preexisting conditions into the mix.

Malcolm Tatum
Malcolm Tatum
Malcolm Tatum, a former teleconferencing industry professional, followed his passion for trivia, research, and writing...
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