What does a Medical Claims Processor do?
Published 3 min read
A medical claims processor is responsible for reviewing and processing insurance claims for healthcare services. They may work in a hospital, clinic, or insurance company. Claims processors ensure that claims are accurate and complete, and that they meet all requirements for payment. They may also contact patients or providers to obtain missing information.
Medical Claims Processor job duties include:
- Review and process medical claims in accordance with insurance company guidelines
- Verify accuracy of medical billing codes and diagnosis codes
- Enter claim information into computer system
- Generate reports to track claims status and identify trends
- Resolve claim discrepancies with insurance companies
- Follow up on unpaid claims
- Appeal denied claims
- Train new employees on claims processing procedures
- Maintain knowledge of updates to insurance company claims processing guidelines
Medical Claims Processor Job Requirements
Education: A Medical Claims Processor typically needs at least a high school diploma, although some jobs may require postsecondary education, such as an associate degree in medical billing and coding.
Certification: Although not always required, some employers may prefer or require certification from organizations such as the American Academy of Professional Coders (AAPC) or the Healthcare Financial Management Association (HFMA).
Experience: Many Medical Claims Processor positions require at least one year of experience in medical billing, coding, or a related field. Some jobs may require more experience, such as two to five years.
Medical Claims Processor Skills
- Accurate Data Entry
- Attention to Detail
- Claims Adjudication
- Computer Literate
- Customer Service
- Eligibility Verification
- Follow-up
- Insurance Benefits Knowledge
- Medical Coding
- Payment Posting
- Provider Relations
- Time Management
Related: Top Medical Claims Processor Skills: Definition and Examples
How to become a Medical Claims Processor
A medical claims processor is responsible for reviewing and processing insurance claims from healthcare providers. They work with both patients and providers to ensure that all documentation is accurate and complete, and that claims are processed in a timely manner. Medical claims processors must have a strong understanding of medical billing and coding, as well as insurance policies and procedures.
To become a medical claims processor, you will need to complete a postsecondary education program in medical billing and coding. Many community colleges offer these programs, which typically take one to two years to complete. In addition to coursework, you will also need to complete an internship or externship in order to gain real-world experience. Once you have completed your education and training, you will be ready to take the certified professional coder (CPC) exam. Passing this exam will give you the credential you need to begin your career as a medical claims processor.
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