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

Jul 5, 2020 / 6 Minutes Read / By Albert

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The complexity of medical claims processing can have a significant effect on the financial health of healthcare providers. Claims analysts are a vital part of the process, since they are responsible for ensuring that claims are accurately coded, billed and processed. Their expertise ensures that claims information is correct and that payments are received as quickly as possible.

Failure to properly analyze and process claims can lead to significant delays in payments, which can have a negative impact on the provider's bottom line. Furthermore, incorrect coding and billing can result in penalties or other consequences from payers, limiting the provider's ability to continue providing quality care.

Steps How to Become

Obtain a Bachelor's Degree. Most employers prefer candidates with a bachelor's degree in a field such as healthcare administration, finance, accounting, or business administration.
Gain Experience. Many employers prefer candidates who have prior experience in the healthcare field or related fields, such as insurance or billing.
Pursue Certification. Becoming certified as a Medical Claims Analyst can be beneficial for job seekers. The American Academy of Professional Coders (AAPC) offers the Certified Professional Coder (CPC) and Certified Professional Coder-Payer (CPC-P) certifications.
Understand Medical Terminology. Medical claims analysts must be familiar with medical terminology, anatomy, physiology, and coding systems. It is also important to stay up-to-date with trends in the healthcare industry.
Learn Computer Skills. Medical claims analysts must have excellent computer skills and be proficient in the use of medical billing software.
Develop Analytical Skills. Medical claims analysts must possess strong analytical skills to be able to identify trends, analyze data, and identify patterns in order to make accurate decisions regarding payment of claims.
Understand Health Insurance Policies. Medical claims analysts must have an understanding of health insurance policies and procedures to ensure accurate reimbursement for services rendered.

One of the most important qualities of a reliable and capable medical claims analyst is the ability to accurately assess the information provided by patients and health care providers. This requires an in-depth knowledge of medical terminology, medical coding, and medical records. The analyst must be able to recognize discrepancies and inconsistencies in the data, as well as any other potential issues that may lead to inaccurate billing.

they must be able to research and analyze all available data to ensure accuracy. Good communication and interpersonal skills are also essential, as the analyst must be able to liaise between health care providers and insurance companies. Finally, a strong work ethic and attention to detail are critical, as it is ultimately the responsibility of the analyst to ensure that all claims are accurate, up-to-date, and free of errors.

You may want to check Medical Receptionist, Medical Coder, and Medical Transcriptionist for alternative.

Job Description

Ensure accuracy and completeness of medical claims data.
Analyze claims data to identify trends and discrepancies.
Review provider coding to ensure accuracy and compliance with government regulations.
Monitor claims processing systems for errors and effectiveness.
Resolve problems related to claims processing and reimbursement.
Work with providers, insurance companies, and other stakeholders to resolve claims disputes.
Maintain current knowledge of health care regulations and reimbursement guidelines.
Prepare reports on claims data and analysis for management review and decision-making.
Develop and implement strategies to improve claims processing efficiency.
Assist with the development of training materials and procedures for claims processing staff.

Skills and Competencies to Have

Knowledge of medical terminology and coding systems (e. g. , ICD-10, CPT, HCPCS).
Familiarity with health insurance policies and procedures.
Proficiency in computer software applications (e. g. , Microsoft Office Suite).
Ability to analyze data to identify trends and develop solutions.
Detail oriented with strong organizational and problem-solving skills.
Ability to work independently and meet deadlines.
Excellent verbal and written communication skills.
Knowledge of healthcare billing systems (e. g. , electronic medical records).
Working knowledge of state and federal healthcare regulations.
Ability to maintain confidentiality of patient information.

Medical Claims Analysts must possess a wide range of skills in order to be successful. Most importantly, they must have a thorough understanding of medical billing and coding procedures and regulations. They must be able to interpret medical terminology and diagnoses codes, as well as analyze the accuracy of the information submitted to insurance companies.

they must be highly organized, able to manage multiple tasks at once, and have strong communication and problem-solving skills. As Medical Claims Analysts are responsible for processing and verifying claims, they must be able to identify errors, inconsistencies, and discrepancies and take appropriate corrective action. Furthermore, they must also be able to analyze data in order to detect potential fraudulent claims.

All of these skills enable Medical Claims Analysts to ensure accuracy, compliance and timely payments for both providers and insurance companies.

Medical Lab Technician, Medical Technologist, and Medical Supply Technician are related jobs you may like.

Frequent Interview Questions

What experience do you have working with medical claims?
How have you managed large volumes of medical claims?
What approaches have you taken to investigate and resolve complex medical claims issues?
Describe a time when you identified a trend in medical claims and developed a solution to resolve it.
What methods have you used to ensure accuracy and compliance with healthcare regulations?
How do you manage customer service inquiries related to medical claims?
What techniques do you use to manage and analyze data related to medical claims?
Describe your experience with preparing reports and presentations related to medical claims.
How do you stay up-to-date on changes in the healthcare industry?
What strategies have you used to build relationships with providers and insurers to ensure efficient processing of medical claims?

Common Tools in Industry

Medical Coding Software. This software helps medical claims analysts to accurately assign codes to medical services and procedures for billing and reimbursement purposes (e. g. CPT, ICD-10).
Claims Editing Software. This software helps medical claims analysts to review and edit medical claims for accuracy and completeness prior to submission (e. g. Change Healthcare).
Data Analytics Software. This software helps medical claims analysts to analyze medical claims data to identify trends, errors, and other patterns (e. g. Tableau).
Automated Claims Processing Software. This software helps automate the claims processing process by validating claims data and pre-populating forms (e. g. HealthEdge).
Claims Tracking Software. This software helps medical claims analysts to track the status of medical claims from submission to payment (e. g. Availity).

Professional Organizations to Know

American Academy of Professional Coders (AAPC)
Medical Group Management Association (MGMA)
National Alliance of Medical Auditing Specialists (NAMAS)
Healthcare Financial Management Association (HFMA)
American Health Information Management Association (AHIMA)
American Medical Billing Association (AMBA)
National Association of Healthcare Revenue Integrity (NAHRI)
National Association of Insurance Commissioners (NAIC)
International Association of Medical Billers and Coders (IAMBC)
Association of Certified Medical Examiners (ACME)

We also have Medical Device Engineer, Medical Device Quality Assurance Engineer, and Medical Illustrator jobs reports.

Common Important Terms

Medical Coding. The process of assigning numeric or alphanumeric codes to medical services, procedures, and diagnoses.
Diagnosis Codes. A set of codes used to identify the medical condition a patient is being treated for.
Procedure Codes. A set of codes used to identify medical procedures performed on a patient.
ICD-10. The International Classification of Diseases, 10th Revision is a set of codes used to classify diseases, injuries, and other health conditions.
HCPCS. Healthcare Common Procedure Coding System is a set of codes used to identify medical products, supplies, and services for billing purposes.
Reimbursement. The process of an insurance company paying for healthcare services provided to a patient.
Claims Settlement. The process of an insurance company assessing and settling a claim for healthcare services provided to a patient.
Coverage Determinations. The process of an insurance company deciding whether or not to cover a healthcare service or procedure.
Utilization Review. The process of an insurance company determining the appropriateness and cost-effectiveness of a healthcare service or procedure.
Medical Necessity. The determination of whether or not a healthcare service or procedure is medically necessary for the diagnosis and treatment of a patient's condition.

Frequently Asked Questions

What is a Medical Claims Analyst?

A Medical Claims Analyst is a professional who reviews, evaluates and processes medical claims submitted to insurance companies. They analyze patient records, reports and other relevant information to determine the accuracy and validity of the claims and provide recommendations on payments or denials.

What qualifications are needed to become a Medical Claims Analyst?

To become a Medical Claims Analyst, you would typically need at least a high school diploma or GED and some experience in the medical field. Depending on the specific job, additional qualifications such as a degree in healthcare administration or a certification in medical billing and coding may be required.

What are the duties of a Medical Claims Analyst?

The primary duties of a Medical Claims Analyst include reviewing, evaluating, and processing medical claims, analyzing patient records, reports, and other relevant information, verifying accuracy and validity of claims, recommending payments or denials, and communicating with insurance companies and other healthcare providers.

What types of software are used by Medical Claims Analysts?

Medical Claims Analysts use computer software such as claims processing software and medical coding software to manage claims and ensure accuracy. They may also use practice management software to track patient records, billing information, and other data.

How much do Medical Claims Analysts make?

According to the U.S. Bureau of Labor Statistics, the median annual salary for Medical Claims Analysts is $47,090 as of May 2020. Salaries for those in the top 10th percentile can reach up to $81,470 per year.