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What is a Medical Claims Specialist?

By Bethany Keene
Updated Mar 02, 2024
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A medical claims specialist is also known as a health claims specialist or medical billing specialist, and is an employee who works for a hospital, doctor's office, or insurance company. The medical claims specialist is responsible for assigning the correct insurance and procedural codes to bills, processing insurance forms, and performing patient billing services. Education requirements vary depending on the physician's office or type of billing to be processed.

A medical claims specialist may only be required to have a high school diploma, and often some experience working in a healthcare environment, usually as an administrative assistant. He or she may then receive on-the-job training to be a claims specialist. Some offices or healthcare businesses require their claims specialists to have an associate's degree in health information technology, however, along with one of the following certifications: Certified Coding Specialist (CCS), Certified Coding Associate (CCA), or Certified Coding Specialist-Physician-based (CCS-P).

Many community and vocational colleges offer classes or certification programs in this type of work. Students learn medical terminology as well as the billing codes necessary for submitting claims to insurance companies. These are known as Current Procedural Technology (CPT) codes and International Classification of Diseases (ICD) codes. It is important for a medical claims specialist to know and understand insurance laws in order to process the claims correctly.

In addition to filling out forms for insurance companies, a medical billing specialist will also need to process payments received from patients and insurance companies, and apply them correctly to various accounts. Disputes often arise between patients and insurance providers, and a medical claims specialist will likely need to spend much of his or her day on the phone resolving these issues, so it is important for a claims specialist to have good customer service skills, and the ability to multi-task efficiently. Medical claims specialists frequently answer questions regarding billing or insurance when patients call the office or call center at a hospital.

Medical claims specialists will need to be neat and organized, as their job will frequently require maintaining a file system. They need to have excellent computer and data entry skills, and a high attention to detail. Some medical claims specialists are able to work from home, once they have established themselves as efficient and careful workers within an office. Typically, a medical claims specialist will work regular weekday hours, and receive a fairly good income with benefits; this makes this career a good choice for many people.

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Discussion Comments
By anon275443 — On Jun 18, 2012

I have worked for some of the biggest health insurance companies, as well as at facilities, with specialty doctors and even with a third party administrator.

I have worked as a claims specialist, a claims auditor, a trainer, insurance verification specialist, claims examiner and much more and I would have to say from a managerial point of view, 67 percent or more of business is handled by overseas reps due to cost.

On the claims specialist side, it's frustrating to talk to someone in disputing claims when they do not understand health care in general because they either don't have health insurance, or they have free health care and thus do not have to deal with these tedious disputes of resolving a claim.

However, all of you are correct: it is definitely a career that has longevity. It's impossible to get rid of such a position as a whole. Claims specialists do not pay very well if you compare the numbers to other positions.

By hamje32 — On Sep 03, 2011

@allenJo - Outsourcing does not necessarily mean overseas. There are third party providers here in the United States who provide medical billing services.

On balance, I think that many doctors’ offices are finding that it’s better to outsource to these companies because they don’t have to pay salaries and benefits.

Of course, if you pursue this field, you could always see if you could work for the third party firm, since they hire experienced coders as well.

However, I still think there is plenty of demand for in house medical coding. If it’s something you really want to do I think you should do it.

By allenJo — On Sep 02, 2011

@everetra - One concern that some people have is whether medical claims jobs as a whole are being outsourced overseas to places like India. I know some hospitals have already begun to do that, which I think is a shame.

You would think that a job which requires good customer service skills would remain in the states. I realize that there is a lot about medical coding that is routine and mostly data entry driven, but when you have to settle a billing dispute you want someone local and easily accessible.

By everetra — On Sep 02, 2011

@Charred - I believe that a medical insurance specialist is a valid career choice; however I don’t think that they would make the kind of money that your newspaper ad described. I think it’s closer to $15 an hour for starting pay, from what I understand.

I do know one person who does the work from home, but she started out working at the office. Because of her newborn child she persuaded the doctor to let her work from home, at least for awhile. It’s not expected, however, that specialists will work from home and the industry generally discourages this practice as it can put the doctors in a bind.

However, it is possible. Like so many things that turn out to be too good to be true, there is a kernel of truth in what the advertisement was promoting but it was a misrepresentation of how many people do their work.

By Charred — On Sep 01, 2011

While I am sure medical claims specialist jobs abound, you should always beware of scams masquerading as work from home opportunities.

Some years ago I answered an ad in a local newspaper that claimed to tell me all I needed to know about becoming a medical billing specialist. All I would have to do is take a course.

For that, they wanted $400 and claimed that I would be making $60,000 a year. Well, fortunately I didn’t even have $400 at the time. After doing some research later on I then discovered that many of these operations were scams; no one can tell you everything you need to know in a work from home course.

Further, as the article rightly points out, most of the legitimate jobs are not work from home – they work on site, in the doctor’s office. It’s a medical career like any other; there are no shortcuts.

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