The primary job in the field of medical claims processing is that of medical claims processor, which is sometimes also known as medical insurance claims adjuster, as the Houston Chronicle explains. Medical claims processors typically work for insurance companies, but some also work for hospitals or doctors' offices. Their main task is to examine insurance claims in relation to the benefits provided by a specific insurance company to determine whether the company should pay the claim.
Medical claims processors must make sure that medical insurance claims submitted by patients are complete and valid. To do this, processors must know how to read medical documents and understand medical terminology. They must be able to retrieve any missing or required information from doctors' offices or the relevant insurance company, and they must keep records on all claims they process, as Study.com details.
A medical claims processor determines how much an insurance company should pay for each claim submitted. The processor doesn't have the authority to approve overpayments. If a claim is valid, the processor approves payment so that the insurance company can pay the doctor or hospital. When processors deny claims, they must inform the patient and the health care provider of the reasons for denial. A medical processor who works for a doctor's office or hospital focuses on getting paid by the insurance company, as explained by the Houston Chronicle.
While the job of medical claims processing has no specific educational requirement, processors can gain certification by taking the Certified Medical Reimbursement Specialist examination. This exam covers the necessary medical terminology as well as knowledge of medical billing codes and insurance fraud, according to Study.com.