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

The increasing complexity of the healthcare system has created a need for knowledgeable, organized professionals to manage physician claims. Physician Claims Specialists are responsible for analyzing and processing a variety of insurance claims for medical services provided by physicians and other healthcare providers. They must be familiar with reimbursement policies, coding systems, and insurance regulations to ensure proper payment for claims.

In addition, they must also have knowledge of medical terminology, billing practices, and claim auditing procedures. By ensuring accurate and timely payment of physician claims, these specialists help maintain a positive relationship between healthcare providers and insurance companies, as well as reduce administrative costs for the healthcare provider.

Steps How to Become

1. Earn a Bachelor's Degree. In order to become a physician claims specialist, you will need to earn a bachelor's degree in a related field such as healthcare administration, finance, or accounting. It is important to make sure that the college or university you choose is accredited.
2. Obtain Professional Certification. Professional certification is not required to become a physician claims specialist, but it can help you stand out from other candidates and demonstrate your expertise in the field. The American Academy of Professional Coders (AAPC) offers a Certified Professional Coder (CPC) certification that can help you qualify for higher-level positions.
3. Gain Experience. Many employers prefer to hire physician claims specialists with at least two years of experience in the field. You can gain this experience by interning at a healthcare facility or working as a medical billing specialist.
4. Improve Your Skills. As a physician claims specialist, you will need to have an in-depth knowledge of medical coding, billing processes, and insurance regulations. You can improve your skills by attending seminars and taking courses related to these topics.
5. Network. Networking is an effective way to find job opportunities as a physician claims specialist. Attend industry events and connect with professionals in the field via LinkedIn or other social media platforms.

Becoming a skilled and competent Physician Claims Specialist requires dedication, hard work and commitment. Firstly, an individual must obtain an appropriate education, such as a degree in health care administration, accounting or finance. This will provide the necessary knowledge and skills in order to be successful in this field.

Once this step is completed, the individual will need to gain experience by working in a related field, such as billing or coding. This will allow them to become familiar with the processes and procedures involved in physician claims. Finally, the individual must stay up-to-date on the latest developments in the industry, such as changes in insurance policies, regulations and procedures.

By dedicating themselves to these activities, an individual can become a skilled and competent Physician Claims Specialist.

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Job Description

1. Review and verify physician and provider claims for accuracy, completeness, and compliance with all applicable regulations.
2. Investigate and resolve discrepancies in claims and seek additional documentation when needed.
3. Monitor and analyze trends in claim processing and identify areas of improvement.
4. Review and audit claim payments to ensure accuracy and compliance with applicable regulations.
5. Research and respond to inquiries from providers, auditors, and payers regarding claim processing.
6. Reconcile accounts and prepare reports related to claim payments and denials.
7. Maintain updated knowledge of applicable regulations, policies, and procedures.
8. Assist in the development of new or updated policies and procedures for claim processing.
9. Stay informed of changes in the healthcare industry that may impact claims processing.
10. Document processes, procedures, and other relevant data in the claims management system.

Skills and Competencies to Have

1. Knowledge of medical billing and coding processes and standards.
2. Ability to effectively analyze and interpret medical records.
3. Excellent organizational and problem-solving skills.
4. Proficient with Microsoft Office Suite, including Excel and Word.
5. Excellent verbal and written communication skills.
6. Ability to work independently and as a team.
7. Ability to manage multiple tasks simultaneously.
8. Ability to handle confidential information with discretion.
9. Knowledge of health insurance plans, benefits, and regulations.
10. Ability to identify discrepancies in data and take corrective action.

The role of a Physician Claims Specialist is critical to the success of a medical practice. A well-trained and experienced Physician Claims Specialist is essential for the efficient processing of medical claims. They must have the ability to accurately interpret insurance policies and regulations, as well as have detailed knowledge of medical coding and billing procedures.

In addition, they must possess strong communication and problem-solving skills in order to effectively address any issues that may arise. Furthermore, they must be well-versed in medical terminology, anatomy, and physiology in order to accurately process claims and identify any potential errors. By having these skills, they are able to ensure that physicians receive the appropriate reimbursement for their services rendered.

This helps to maintain a healthy financial flow for a medical practice and ensure that patients receive the medical care they need.

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Frequent Interview Questions

• What experience do you have in working with physicians and claims processing?
• What do you understand to be the primary responsibilities of a Physician Claims Specialist?
• How do you stay up to date on changes in the medical claims processing industry?
• What strategies do you use to ensure accurate and timely processing of claims?
• Describe a time when you successfully resolved a complex claim issue.
• How do you handle claims that require manual intervention?
• What methods do you use to detect and correct duplicate claims?
• How do you handle difficult conversations with physicians about billing discrepancies?
• How do you ensure compliance with federal and state regulations regarding physician claims?
• What systems have you worked with for submitting and tracking physician claims?

Common Tools in Industry

1. Medical Billing Software. A software program used to track and process patient billing information, such as insurance claims and payments. (e. g. Kareo)
2. Practice Management Software. Software designed to help healthcare providers manage the administrative aspects of running their businesses. (e. g. Athenahealth)
3. Electronic Health Record (EHR) Software. Software that stores patient data such as medical history, diagnosis, treatment, and test results in a secure, digital format. (e. g. NextGen EHR)
4. Revenue Cycle Management (RCM) Software. Software that helps manage the revenue cycle, including insurance claims, billing, and collections. (e. g. MediRevv RCM)
5. Coding Software. Software that helps healthcare providers accurately assign diagnostic and procedural codes to patient records. (e. g. 3M Coding and Reimbursement System)
6. Claims Editing Software. Software that helps identify coding errors and potential compliance issues in patient claims before they are submitted to insurers. (e. g. McKesson ClaimCheck)
7. Claim Analysis and Auditing Software. Software that helps identify discrepancies in patient claims and analyze trends in billing data. (e. g. Change Healthcare Claim Analysis)
8. Fraud Detection Software. Software designed to help identify potential fraudulent activity by analyzing patient claims data. (e. g. RelayHealth Fraud Detection)

Professional Organizations to Know

1. American Medical Association
2. American Academy of Family Physicians
3. American College of Physician Executives
4. American Osteopathic Association
5. American College of Healthcare Executives
6. American Health Information Management Association
7. Healthcare Financial Management Association
8. Medical Group Management Association
9. National Association of Medical Staff Services
10. American Health Lawyers Association

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Common Important Terms

1. Coding. The process of assigning numerical codes to medical diagnoses and procedures in order to accurately communicate medical information between providers and payers.
2. Claims Processing. The process of validating, processing, adjudicating, and paying medical claims submitted by providers.
3. Healthcare Reimbursement. The process of reimbursing healthcare providers for services rendered by submitting claims to insurance companies and other payers.
4. Medical Necessity. The determination of whether a particular service or treatment is medically necessary for a patient based on their unique medical history and condition.
5. Utilization Review. The process of reviewing the appropriateness of a service or treatment for a patient based on their unique medical history and condition.

Frequently Asked Questions

What is a Physician Claims Specialist?

A Physician Claims Specialist is a health care professional who reviews and processes medical insurance claims to ensure accurate reimbursement from insurance companies.

What are the responsibilities of a Physician Claims Specialist?

A Physician Claims Specialist is responsible for reviewing and verifying patient information and medical codes, researching claims for accuracy, communicating with insurance companies to resolve discrepancies, and ensuring timely payment of claims.

What qualifications are required to become a Physician Claims Specialist?

To become a Physician Claims Specialist, individuals typically need to have a degree in health care administration or a related field, as well as experience in medical billing and coding. Knowledge of medical terminology and coding regulations is also important.

How much does a Physician Claims Specialist earn?

According to the U.S. Bureau of Labor Statistics, the median annual salary for a Physician Claims Specialist is $44,600. Pay can vary depending on experience, location, and employer.

What organizations offer certification for Physician Claims Specialists?

Professional organizations such as the American Academy of Professional Coders (AAPC) and the National Association of Healthcare Quality (NAHQ) offer certification for Physician Claims Specialists.

What are jobs related with Physician Claims Specialist?

• Physician Assistant
• Physician Practice Manager
• Physician Coder
• Physician Consultant
• Physician Network Administrator
• Physician Clinical Documentation Specialist
• Physician Scheduler
• Physician Recruiter
• Physician Executive

Web Resources

• Medical Claims Service Specialist - University of Montana www.umt.edu
• Health Insurance Coding and Claims Specialist - Delta … www.delta.edu
• Physician Claim History - rmf.harvard.edu www.rmf.harvard.edu