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

Sep 24, 2023 / 5 Minutes Read / By Albert

How to Become

Professional Organizations

FAQ

Links

When an ophthalmic claims examiner is assigned to review a case, they must assess the validity of the claim and determine if the patient should receive the services they have requested. They evaluate the medical evidence and review the patient's medical history to determine if the services are medically necessary. If the ophthalmic claim is approved, the patient receives the services they have requested and can benefit from a better quality of care.

If the claim is denied, the patient must seek an alternative provider and may face financial hardship due to additional costs. This process is critical to ensure that patients are receiving appropriate care and that the healthcare system is not overburdened by unnecessary expenses.

Steps How to Become

Obtain a high school diploma or equivalent. Most employers will require a high school diploma or its equivalent, such as a GED, to become an ophthalmic claims examiner.
Enroll in an accredited college or university. Many employers prefer to hire those who have achieved an associate's degree or higher in a field related to medical coding.
Become certified in medical coding. Becoming certified in medical coding can increase your chances of becoming an ophthalmic claims examiner. The American Academy of Professional Coders (AAPC) offers several different medical coding certifications, including the Certified Professional Coder (CPC), Certified Ophthalmic Coder (COC), and Certified Ophthalmic Technician (COT).
Gain experience in medical billing and coding. Working in a medical office or hospital setting can provide valuable experience in medical billing and coding, which is beneficial when seeking a job as an ophthalmic claims examiner.
Apply for jobs as an ophthalmic claims examiner. Once you have the necessary education, certification, and experience, you can begin applying for jobs as an ophthalmic claims examiner.

The key to becoming an efficient and updated Ophthalmic Claims Examiner is to stay abreast of any changes in the industry. This can be accomplished by attending conferences, reading industry journals, participating in online forums, and staying informed of the latest updates from organizations such as the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery. By actively engaging in these activities, Ophthalmic Claims Examiners can better understand the most recent developments in the industry and be better prepared to handle future claims.

In addition, staying up-to-date on technology trends in the industry can help Ophthalmic Claims Examiners stay ahead of the curve in terms of efficiency. With the right knowledge, Ophthalmic Claims Examiners can stay ahead of the competition and keep their claim processing times at a minimum.

You may want to check Ophthalmic Reimbursement Coordinator, Ophthalmic Clinical Supervisor, and Ophthalmic Diagnostic Technician for alternative.

Job Description

Review patient medical records and insurance documentation to determine coverage eligibility.
Process and adjudicate ophthalmic claims according to insurance company standards, policies, and procedures.
Resolve claim discrepancies by researching patient records and insurance coverage guidelines.
Utilize knowledge of computer systems and software to enter data, access information, and generate reports.
Communicate with insurance companies, providers, and customers to clarify information and resolve discrepancies.
Accurately document account activity in the system.
Identify and document any potential fraud or abuse and escalate potential issues to management.
Provide customer service and respond to inquiries from providers and customers.
Maintain up-to-date knowledge of billing regulations, coding guidelines, and reimbursement policies.
Monitor changes in regulations and adjust workflow processes accordingly.

Skills and Competencies to Have

Knowledge of medical terminology and coding
Ability to interpret and analyze claims, diagnoses, and insurance plans
Familiarity with HIPAA regulations and other applicable laws
Excellent organizational, communication, and customer service skills
Ability to multi-task and manage multiple priorities
Strong attention to detail
Proficiency in computer applications such as Microsoft Office
Experience with ophthalmic claims and billing systems
Ability to identify errors or discrepancies in claims data
Ability to work independently and in a team environment

Ophthalmic Claims Examiners are in high demand due to the critical nature of their job. Their primary responsibility is to process and review insurance claims for medical procedures performed by ophthalmologists. To be successful in this role, an Ophthalmic Claims Examiner must possess strong analytical skills and be highly organized.

They must be able to review medical records and documents, accurately assess the need for services, and determine the amount of reimbursement due to the ophthalmologist. An Ophthalmic Claims Examiner must also have excellent communication skills in order to explain complex billing codes to patients and providers, as well as to negotiate with insurance companies. In addition to these skills, they must have a comprehensive understanding of medical terminology, insurance policies and regulations.

By having these skills and knowledge, an Ophthalmic Claims Examiner can ensure that claims are processed efficiently and accurately, resulting in a positive financial outcome for both the ophthalmologist and the patient.

Ophthalmic Patient Care Coordinator, Ophthalmic Laboratory Technician, and Ophthalmic Claims Processor are related jobs you may like.

Frequent Interview Questions

What experience do you have in ophthalmic claims processing?
How have you successfully managed difficult claims?
Describe your experience with interpreting insurance policies and understanding the legal language of plans.
What challenges have you faced in the past when working with ophthalmic claims?
What methods do you use to prioritize tasks and stay organized?
How do you ensure accuracy and completeness when examining claims?
What techniques do you use to detect fraudulent claims?
What strategies do you use to communicate with insurers and providers?
Describe a time when you had to go above and beyond to resolve a claim dispute.
How do you stay up-to-date on changes in ophthalmic claims regulations?

Common Tools in Industry

Electronic Health Record System (EHR). An electronic system used to store and manage patient health information such as diagnoses, prescriptions, and treatments. (eg: Epic Systems)
Coding Software. Software used to accurately identify and classify medical diagnoses and procedures for billing purposes. (eg: 3M Coding Software)
Billing Software. Software used to track and submit healthcare claims to insurance companies in a timely manner. (eg: Practice Management Software)
ICD-10 Database. A database used to look up International Classification of Diseases codes that are used to bill insurance companies for medical services. (eg: UpToDate ICD-10 Database)
Medical Terminology Dictionary. A dictionary used to look up medical terms and abbreviations in order to understand medical reports. (eg: Taber's Medical Dictionary)
Claims Auditing Software. Software used to review insurance claims for accuracy and completeness. (eg: RelayHealth Claims Auditing Software)

Professional Organizations to Know

American Academy of Ophthalmology
American Board of Ophthalmology
American Society of Cataract and Refractive Surgery
Association of Optometric Contact Lens Educators
American Optometric Association
National Board of Examiners in Optometry
Opticians Association of America
International Association of Ophthalmologists
National Association of Vision Care Plans
American Society of Ophthalmic Registered Nurses

We also have Ophthalmic Practice Manager, Ophthalmic Technician Trainer, and Ophthalmic Quality Assurance Analyst jobs reports.

Common Important Terms

Pre-Certification. The process of obtaining authorization from an insurance company prior to a patient receiving a medical service or procedure.
Co-Pay. The amount of money that an insured individual must pay out-of-pocket for a medical service or procedure.
Deductible. The amount of money an insured individual must pay before their insurance company will begin to cover the costs of a medical service or procedure.
EOB (Explanation of Benefits). A document that explains to the insured individual and/or provider the details of a claim payment, including what was paid and what the patient owes.
HIPAA (Health Insurance Portability and Accountability Act). Legislation in the United States that sets national standards for the protection of confidential patient health information.
ICD-10 (International Classification of Diseases, 10th Revision). A system of medical coding developed by the World Health Organization to classify health conditions and diseases for the purpose of accurate billing and reimbursement.
CPT (Current Procedural Terminology). A system of medical coding developed by the American Medical Association for procedures and services performed by healthcare providers.
HCPCS (Healthcare Common Procedure Coding System). A system of medical coding developed by the Centers for Medicare & Medicaid Services for procedures and services not covered by CPT codes.

Frequently Asked Questions

What qualifications are required to be an Ophthalmic Claims Examiner?

To become an Ophthalmic Claims Examiner, you must have at least a high school diploma or its equivalent, plus experience in medical claims processing and knowledge of ophthalmic coding.

What responsibilities does an Ophthalmic Claims Examiner have?

Ophthalmic Claims Examiners are responsible for reviewing ophthalmic insurance claims for accuracy and completeness before submitting them to the insurance company for payment. They also verify coding and billing information and ensure that all services were medically necessary.

What skills are required for an Ophthalmic Claims Examiner?

Ophthalmic Claims Examiners must have strong computer skills, as well as excellent attention to detail and the ability to multitask. They must also have strong communication and problem-solving skills, as well as a good understanding of medical terminology and insurance coding.

How much does an Ophthalmic Claims Examiner typically earn?

According to the Bureau of Labor Statistics, the median annual salary for an Ophthalmic Claims Examiner is $42,830 as of May 2019.

What type of work environment do Ophthalmic Claims Examiners work in?

Ophthalmic Claims Examiners typically work in a medical office environment, such as a hospital, clinic, or private practice. They may also work remotely from their own home.