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

Sep 15, 2022 / 5 Minutes Read / By Albert

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The growth of healthcare delivery and the increasing cost of medical services have led to an increased demand for claims processors in the insurance industry. As a result, claims processors are responsible for verifying the accuracy of insurance claims, calculating payments, and ensuring compliance with applicable regulations. By performing these duties, claims processors help protect the financial stability of insurance companies and their customers.

In addition, they help to ensure that healthcare providers are paid in a timely manner and that patients receive the coverage they are entitled to under their policies. claims processors are essential to the successful operation of the insurance industry, as they help to ensure that healthcare costs are kept to a minimum and that quality care is being provided.

Steps How to Become

Obtain a high school diploma or equivalent. Most claims processor positions require a high school diploma or equivalent.
Consider obtaining a college degree. Some employers prefer college graduates for claims processor positions. Relevant degrees may include business administration, finance, accounting, or health information management.
Obtain entry-level experience. Claims processors often obtain entry-level experience in the insurance industry. This experience may include administrative duties such as filing, customer service, and data entry.
Complete a training program. Insurance companies often provide on-the-job training for claims processor positions. This training may include instruction on insurance policies, software programs, and customer service techniques.
Take an exam. Some states require claims processors to pass a licensing exam in order to work in the insurance industry.
Obtain certification. Obtaining certification from the National Association of Insurance Commissioners (NAIC) may help improve job prospects.

When it comes to being an efficient and ideal Claims Processor, there are a few key steps that need to be taken. Firstly, having a strong understanding of the insurance policies and coverage is essential. Knowing what is covered or not covered and how different policies interact can make a huge difference in how quickly a claim is processed.

Secondly, staying organized is critical. Keeping track of the paperwork, documentation, and other tasks associated with a claim will help keep everything on track. Lastly, communication is key.

Maintaining contact with the customer throughout the claims process, including keeping them informed of progress, is important for a successful outcome. By following these steps, a Claims Processor can ensure that claims are handled quickly and efficiently.

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Job Description

Review insurance claims to determine eligibility for coverage and payment.
Input claims data into the computer system for processing.
Contact insurance companies for additional information and to verify accuracy of claim information.
Calculate payments due according to policy limits, contracts, and applicable regulations.
Communicate with claimants to answer questions and provide claim status updates.
Process adjustments and corrections to claims as needed.
Reconcile accounts and prepare reports as needed.
Maintain records of all claims processed.
Keep up with industry trends and changes in regulations.
Resolve complex claims issues, discrepancies, and disputes.

Skills and Competencies to Have

Knowledge of insurance policies and procedures
Understanding of medical terminology
Proficiency in data entry
Excellent organizational skills
Ability to work independently and manage multiple tasks simultaneously
Ability to communicate effectively with internal and external customers
Attention to detail and accuracy
Computer literacy and proficiency in Microsoft Office Suite
Knowledge of relevant software and applications
Ability to research and analyze claims data
Problem-solving and conflict resolution skills
Ability to interpret and follow complex instructions
Ability to maintain confidentiality of sensitive information

Claims processing is a critical role in the insurance industry as it involves verifying, reviewing, and processing claims from policyholders. The success of an organizations claims process relies heavily on the expertise and attention to detail of the claims processor. To be successful in this role, it is essential to have strong problem-solving skills and a deep understanding of the coverage, procedures, and regulations that govern the insurance industry.

Furthermore, having a customer service orientation is a must, as claims processors often need to interact with policyholders and provide them with helpful advice. Other important skills include excellent communication, organizational, and analytical abilities, as well as the ability to handle large volumes of data with accuracy and precision. With these skills, a claims processor can ensure that policyholders receive timely and accurate payments for their claims.

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Frequent Interview Questions

What experience do you have in the field of claims processing?
What is your approach to meeting deadlines while handling multiple claims?
How do you ensure accuracy when entering data and making decisions?
How do you stay informed of changes in the relevant laws and regulations pertaining to claim processing?
How would you handle a difficult customer situation while processing a claim?
What strategies do you use to ensure compliance with all applicable rules and regulations?
In what ways have you improved processes or procedures in your past positions related to claims processing?
Describe a time when you had to investigate an issue related to a claim and how did you resolve it?
What techniques do you use to maintain professional relationships with insurance companies and other entities involved in claim processing?
How do you prioritize tasks when dealing with competing demands from different stakeholders?

Common Tools in Industry

Electronic Medical Record System (EMR). This tool is used to store, manage and share patient records electronically. Example: EpicCare EMR.
Claims Management System (CMS). This tool is used to track, process and manage claims electronically. Example: Change Healthcare CMS.
Automated Workflow System (AWS). This tool automates the claims processing process by automating tasks such as document routing, tracking, and data entry. Example: Change Healthcare AWS.
Data Analytics Tool. This tool is used to analyze claims data to identify trends and patterns to improve claims processing efficiency. Example: Change Healthcare Data Analytics Tool.
Document Management System (DMS). This tool is used to store, organize and share documents related to the claims processing process. Example: Lexmark DMS.

Professional Organizations to Know

American Health Information Management Association (AHIMA)
International Association of Privacy Professionals (IAPP)
Health Care Compliance Association (HCCA)
National Association of Healthcare Access Management (NAHAM)
American Academy of Professional Coders (AAPC)
Healthcare Financial Management Association (HFMA)
American Association of Medical Audit Specialists (AAMAS)
American Association of Medical Billers and Coders (AAMBC)
American Society of Health Information Management Systems (ASHIMS)
Medical Group Management Association (MGMA)

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Common Important Terms

Insurance Carrier. An insurance company that provides insurance coverage to policyholders.
Claims Adjuster. A professional who evaluates insurance claims and determines a reasonable settlement amount.
Claim Denial. When an insurance company refuses to cover a claim.
Claim Reimbursement. The process of reimbursing a policyholder for a covered claim.
Claims Investigation. A process used by an insurance company to verify the legitimacy of a claim.
Subrogation. The process of an insurance company seeking reimbursement from a third party, such as another insurer, for payments made to a policyholder.
Benefit Payment. A payment made by an insurance company to a policyholder or other authorized individual for a covered claim or service.
Medical Documentation. Records, such as medical reports or bills, used to determine the validity of a claim.

Frequently Asked Questions

What is a Claims Processor?

A Claims Processor is a professional responsible for processing insurance claims, verifying accuracy and ensuring their timely payment.

What qualifications are necessary for a Claims Processor?

To become a Claims Processor, one must typically have a high school diploma or equivalent and some experience in the insurance industry. Knowledge of medical terminology and coding is also beneficial.

How much does a Claims Processor make annually?

According to PayScale.com, the average annual salary for a Claims Processor is $37,822.

What is the job outlook for Claims Processors?

The job outlook for Claims Processors is expected to remain steady. With the increasing complexity of health care and insurance regulations, there will be a growing need for professionals to manage insurance claims.

What are some of the duties of a Claims Processor?

A Claims Processor's duties typically include reviewing and verifying insurance claims, ensuring accuracy and completeness, submitting claims to payers, managing denials, and providing customer service regarding claims processing.