How to Be Claims Processing Specialist - Job Description, Skills, and Interview Questions

Jul 20, 2023 / 5 Minutes Read / By Albert

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Claims processing is an essential part of the insurance industry as it is the process of verifying insurance claims submitted by policyholders. This process involves reviewing claims forms, processing payments, and verifying coverage. It is a complex process that requires accuracy and attention to detail.

When claims are processed incorrectly or not in a timely manner, it can cause a number of negative effects. These can include financial losses for both the policyholder and the insurer, as well as increased customer dissatisfaction due to delays in payment. processing errors can lead to legal issues if claims are denied without due cause.

To ensure that claims are processed correctly and efficiently, insurers rely on specialized personnel, such as claims processing specialists, to handle the task. These professionals are responsible for verifying coverage, submitting accurate paperwork, and providing timely payment to policyholders. By utilizing the expertise of claims processing specialists, insurers can help avoid costly errors and ensure that their policyholders are satisfied with their service.

Steps How to Become

Earn a High School Diploma or GED. Most employers require that Claims Processing Specialists have at least a high school diploma or GED. Some also require that applicants have some college education.
Complete a Post-Secondary Certificate. Some employers may require that applicants have a certificate or post-secondary degree in medical coding or another relevant field.
Obtain Certification. Certification is offered through professional organizations such as the American Academy of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA).
Gain Experience. Most employers require at least one year of experience in medical coding or claims processing. Experience can be gained on the job or through internships or volunteer positions.
Advance Your Career. Specialty certifications are available for experienced professionals who want to advance their career. Many employers prefer to hire certified professionals.

Claims processing specialists are tasked with the important job of validating and processing insurance claims for healthcare and other services. This job requires a high level of accuracy and attention to detail, as well as a deep understanding of the claims process. Skilled and efficient claims processing specialists must be organized, have strong problem solving skills, and be able to work within tight deadlines.

Furthermore, they must be knowledgeable about coding and billing practices, and have a clear understanding of insurance policies and regulations. When claims are processed accurately and in a timely manner, it helps to ensure that patients receive the care they need, while also helping organizations to manage their finances effectively.

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Job Description

Ensure accurate and timely processing of all claims by researching and verifying data entered into the system.
Perform timely and accurate data entry of claims information into the claims processing system.
Review, analyze and process all incoming claims in accordance with established procedures and guidelines.
Identify, investigate and resolve any discrepancies in the claims data.
Monitor and track claim status and adjust as needed to ensure prompt payment.
Utilize various systems to research and verify information related to claims.
Respond to customer inquiries regarding claim status, coverage, and other questions related to claims processing.
Escalate issues to managers as needed for resolution.
Maintain organized records of all claims processing activities.
Ensure compliance with all applicable laws, regulations, and policies pertaining to claims processing.

Skills and Competencies to Have

Knowledge of healthcare insurance and claims reimbursement processes.
Demonstrated ability to accurately and efficiently process a high volume of claims.
Familiarity with relevant medical coding conventions and regulations.
Proficiency in Microsoft Office Suite applications, including Excel and Word.
Excellent attention to detail and strong problem-solving skills.
Ability to work with minimal supervision in a fast-paced environment.
Excellent communication skills, both written and verbal.
Ability to build rapport with clients and maintain effective relationships.
High level of organization and time management skills.
Ability to multi-task and prioritize tasks based on importance and urgency.

Claims processing specialists are essential in the insurance industry, as they are responsible for processing claims quickly and accurately. The ability to think critically and analyze data is essential for this role, as is the ability to understand the legal implications of insurance policies. Strong organizational skills, attention to detail, and problem-solving abilities are also necessary for success in this role.

having excellent customer service skills is important in order to build trust with customers and help them through difficult times. By possessing these skills, claims processing specialists can ensure that every claim is handled appropriately and efficiently, keeping customers satisfied and helping the insurance company maintain a positive reputation.

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Frequent Interview Questions

How do you stay organized when managing multiple claims?
What experience do you have processing claims in a timely manner?
What experience do you have with customer service?
How would you handle a situation where a customer is unhappy with the outcome of their claim?
How do you stay up to date on the latest rules and regulations related to claims processing?
In your experience, what has been the most difficult type of claim to process?
Describe a time when you had to manage conflicting priorities while processing claims.
Have you ever had to reject a claim and how did you handle it?
Explain your experience with using computer software to manage and track claims.
How do you ensure accuracy when entering data related to claims processing?

Common Tools in Industry

Claim Intake Software. Allows claims processing specialists to quickly and accurately process claims, including verifying patient data and insurance information. (eg: ClaimLogic)
Claim Management System. Automates claim processing, from initial intake to adjudication and payment. (eg: McKesson Claim Management)
Electronic Medical Record (EMR) Software. Automates patient medical records, allowing claims specialists to quickly review patient histories. (eg: Epic EMR)
Claims Auditing Software. Automates the process of auditing claims for accuracy and compliance with regulations. (eg: eClaimAudit)
Data Analysis Software. Utilizes advanced analytics to help identify claims fraud and inefficiencies in the claims processing process. (eg: IBM Watson Analytics)
Claims Denial Management Software. Automates the process of identifying and resolving denied claims. (eg: MediRevv Denial Management Software)

Professional Organizations to Know

American Medical Billing Association (AMBA)
Healthcare Billing & Management Association (HBMA)
American Academy of Professional Coders (AAPC)
National Society of Professional Coders (NSPC)
American Health Information Management Association (AHIMA)
American Association of Medical Auditors (AAMA)
Healthcare Financial Management Association (HFMA)
Medical Group Management Association (MGMA)
Academy of Professional Coders (APC)
Association of Certified Professional Billers (ACPB)

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Common Important Terms

Claim Form. A form used to submit a request for payment of services or goods.
Claim Adjuster. An individual who evaluates and adjusts insurance claims.
Claim Denial. A decision to not pay a claim due to lack of coverage or insufficient evidence.
Claim Investigation. A process of gathering evidence to decide the validity of a claim.
Claim Payment. Sending the claimant a check or other form of payment in accordance with their claim.
Claim Reimbursement. The process of reimbursing a claimant for expenses related to their claim.
Fraud Detection. The process of identifying fraudulent activities regarding insurance claims.
Medical Necessity. A determination made by an insurance provider deciding whether or not a medical treatment is necessary for a given condition.
Precertification. A process in which a health insurer approves certain medical services before they are provided to the insured individual.
Subrogation. The process in which an insurance company can pursue a third party for reimbursement on behalf of the insured individual.

Frequently Asked Questions

What are the main duties of a Claims Processing Specialist?

The main duties of a Claims Processing Specialist include reviewing, verifying and processing claims in accordance with established procedures; entering data into a computerized system; responding to customer inquiries; and handling denied claims.

What qualifications are necessary to become a Claims Processing Specialist?

Qualifications for becoming a Claims Processing Specialist typically include a high school diploma or GED, experience in customer service and data entry, and knowledge of medical terminology.