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What is a Medical Claims Analyst?

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  • Written By: D. Jeffress
  • Edited By: Jenn Walker
  • Last Modified Date: 18 November 2016
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A medical claims analyst works at a private insurance company or government organization to process patient health-care claims. He or she is trained to interpret the codes and terminology commonly used in medical billing to fully understand the paperwork that is submitted by health care providers. The medical claims analyst must determine whether to accept or deny coverage for patients based on policy guidelines, diagnoses, and the services that were provided at the hospital. In order to be a successful analyst, an individual must be very detail-oriented and have strong communication and computer skills.

People purchase health insurance policies to cover the bulk of experiences should they need to visit the hospital or a doctor's office. When an individual does indeed receive diagnostic tests and treatment, the doctor passes on his or her medical records to a billing specialist to code information and submit it to the insurance company. Medical billing experts rely on a specialized type of coding procedure to categorize illnesses, diagnoses, and treatments in a standardized chart. Coded information is relayed to a medical claims analyst at the patient's insurance company for careful processing.

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When the analyst receives information, he or she carefully reads through charts to understand everything about the patient's hospital visit. The analyst retrieves the patient's policy, determines if it covers the services provided, and processes the claim accordingly. The analyst decides if a visit was necessary and if policy details actually cover the treatment received. He or she must rigorously follow legal and company standards regarding patient confidentiality, proper billing procedures, and reimbursement techniques.

Communication and technical skills are generally essential to perform the job. A medical claims analyst usually receives information via e-mail and uses specialized software programs to enter and manipulate claims data. He or she frequently speaks with medical billing specialists on the telephone and through e-mail correspondence to clarify information.

The education and training requirements to become a medical claims analyst vary between regions and companies. Most employers prefer to hire analysts who have completed associate's degree programs in health information technology from accredited community colleges. Some large companies require applicants for medical claims analyst positions to hold bachelor's degrees in nursing, pharmacy, or business administration. In addition to completing school programs, new analysts usually spend several weeks in training at their places of employment under the supervision of experienced professionals.

Once a new analyst is comfortable with the job duties, he or she is usually allowed to process small claims that supervisors deem relatively easy to handle. With experience and proven skills, the analyst can begin working more independently and taking on more difficult tasks. Many medical claims analysts who perform well in their jobs for many years have the opportunity to become managers of entire claims departments at their companies.

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