Medical / Health Claims Examiner

Medical and health claims examiners generally work in an office setting, but may be required to go into the field if a situation requires hands-on investigation. Those in this position serve customers of medical insurance companies by determining insurance coverage, claim examination, and resolution, as well as maintaining and documenting customer service actions and ensuring legal compliance. They also determine covered medical insurance losses according to policies/certificates, establish proof of losses by analyzing medical documentation, provide support to legal actions by assembling documentation for settlements, and, if necessary, assemble further information from outside sources and witnesses.There are elements of detective work in this position; questionable claims must be investigated and customer confidentiality and privacy concerns must be respected. Claims examiners must document claims actions and fill out required paperwork with meticulous attention to detail and are the first line for approving or denying claims. They are also responsible for calculating due benefits, initiating payments, and composing denial letters.Because the job also has elements of accounting, investigation, and legal compliance issues, the required skills and qualifications for the position are relatively broad in scope. Experience in the fields of claims adjustment and financial software, as well as skills in documentation, data entry, mathematics, problem-solving, statistical analysis, and customer focus, are also important. They must be familiar with all FDA health regulations, as well.Those in this position generally work regular hours with holidays and benefits.

As a Medical/Health Claims Examiner with 0-3 years of experience in Canada, your main responsibilities include:

• Reviewing medical claims for accuracy, completeness, and adherence to policies and procedures. Ensure that all submitted medical claims are thoroughly reviewed to verify information and prevent fraudulent activities.
• Determining coverage eligibility and benefits for policyholders. Assess policy terms and conditions to determine the extent of coverage and benefits available to policyholders.
• Communicating with healthcare providers and policyholders regarding claim status and required documentation. Maintain effective communication channels to provide updates, request additional information, and resolve any claim-related queries.
• Adhering to regulatory guidelines and industry standards in claims processing.

For a Medical/Health Claims Examiner, the following qualifications are required:

• In-depth knowledge of medical coding systems (such as ICD-10, CPT, HCPCS) and insurance billing processes to accurately review and process healthcare claims.
• Strong attention to detail and analytical skills to evaluate claims for accuracy, completeness, and adherence to policy guidelines.
• Familiarity with medical terminology, procedures, and diagnosis codes to effectively interpret and assess claim information.
• Excellent communication and interpersonal skills to liaise with healthcare providers, insurance companies, and policyholders to resolve claim-related issues and inquiries promptly.

The role of a Medical/Health Claims Examiner is crucial in the healthcare industry, particularly for individuals with 0-3 years of experience in Canada. If you're looking for alternative roles in this field, consider the following options:

• Medical Coder: A position that involves assigning diagnostic and procedural codes to medical records for billing and reimbursement purposes.
• Healthcare Compliance Specialist: A role focused on ensuring adherence to regulatory requirements, policies, and procedures within the healthcare organization.
• Health Information Technician: A position that involves managing and organizing patient health records, ensuring accuracy and confidentiality.
• Healthcare Claims Analyst: A role that involves analyzing and reviewing medical claims for accuracy, completeness, and compliance with insurance policies and guidelines.

According to Google, the projected growth of the Medical/Health Claims Examiner role in Canada is positive. Over the past 10 years, the job role has seen steady growth in the market. The demand for this position is expected to continue increasing in the coming years, resulting in numerous employment opportunities. While specific figures were not provided, the data suggests a favorable job outlook for Medical/Health Claims Examiners in Canada. Please note that for detailed and accurate information, it is recommended to consult official government or industry sources.