How to Become a Claims Examiner in 2025
What Does a Claims Examiner Do?
A claims examiner, also known as a claims adjuster or claims specialist, is a person who investigates insurance claims to determine if the insurance company is obligated to pay. They play a very important role in the healthcare system by reviewing medical bills and records submitted for payment by doctors, hospitals, and other healthcare providers. This career is appealing to people who are detail-oriented and enjoy working with numbers and medical information.
The core responsibility of a claims examiner is to evaluate medical claims for accuracy and legitimacy. This involves several steps. They begin by checking the claim form to make sure all the required information is present, such as the patient's name, insurance policy number, the medical codes for the services provided (CPT and ICD codes), and the amount charged. They then verify the patient's insurance coverage to confirm the patient was covered at the time the services were received.
A key part of a claims examiner's job is to determine if the services billed were medically necessary and appropriately coded. This often requires a good knowledge of medical terminology, anatomy, and physiology. Claims examiners may need to contact healthcare providers to get more information or clarification about the services billed. They may also use coding guidelines and payer policies to determine if the codes used on the claim are correct. If they find errors or inconsistencies, they may deny the claim, adjust the payment, or request additional documentation. The goal is to make sure that only valid claims are paid and that healthcare providers are paid accurately and fairly, based on their contracts with the insurance company.
Here are some definitions to help further explain the roles of a claims examiner:
- Claim: A request for payment submitted to an insurance company for medical services.
- CPT Codes: Standardized codes used to report medical procedures and services.
- ICD Codes: Codes used to diagnose diseases, injuries, and other health conditions.
For more insight on the role of insurance companies check out the AHIP website: https://www.ahip.org/
Claims Examiner Educational & Certification Requirements
Becoming a claims examiner often starts with obtaining the right education and, sometimes, certifications. A high school diploma or GED is a baseline requirement. Many employers prefer candidates with some college coursework or an associate's degree. Coursework in medical terminology, anatomy, physiology, and coding is particularly helpful. These subjects provide a foundation for understanding medical records and billing practices, which are crucial for evaluating claims.
While a specific degree isn't always mandatory, having one in a field like healthcare administration, business administration, or a related area can give you a competitive edge. These programs teach skills such as data analysis, communication, and problem-solving, all of which are important in claims examination. Some community colleges and vocational schools offer certificate programs specifically aimed at preparing individuals for careers in medical billing and coding, often including claims processing.
Certifications aren't always required for entry-level positions, but earning one can demonstrate your knowledge and commitment to the profession. Organizations like the American Academy of Professional Coders (AAPC) and the Professional Association of Healthcare Coding Specialists (PAHCS) offer certifications related to medical coding and billing, which indirectly benefit claims examiners. These credentials validate your skills and increase your chances of getting hired and advancing your career. Visit AAPC's homepage for more information: https://www.aapc.com/ and PAHCS's homepage here: https://www.pahcs.org/
Training is also a vital part of becoming a claims examiner. Many employers offer on-the-job training to new hires, teaching them about their specific systems and procedures. This training may cover topics like claims processing software, insurance regulations, and company policies. Continuous learning is important in this field, as insurance regulations and medical coding guidelines are subject to change. Participating in workshops, seminars, and online courses can help you stay up-to-date on the latest industry trends and best practices.
Step-By-Step Guide to Becoming a Claims Examiner
Becoming a claims examiner involves several key steps. A claims examiner reviews insurance claims to determine whether the insurance company is required to pay the claim. They look at the claim details, policy information, and supporting documentation, such as medical records or police reports. Follow this path to start your career.
Step 1: Obtain a High School Diploma or GED.
A high school diploma or equivalent is the minimum educational requirement for most claims examiner positions. Strong communication and analytical skills developed during high school are helpful.
Step 2: Consider Post-Secondary Education (Optional but Recommended).
While a college degree isn't always required, it can significantly increase your job prospects. An associate's or bachelor's degree in business, finance, healthcare administration, or a related field provides a solid foundation. Coursework in medical terminology, anatomy, and physiology can be extremely beneficial, particularly for those interested in examining medical claims.
Step 3: Gain Relevant Experience.
Many entry-level claims examiner positions require some experience in a related field. This could include customer service, data entry, or administrative work within an insurance company or healthcare provider's office. Some employers offer entry-level positions like claims assistant or processor, which can be a good way to gain experience and learn the ropes.
Step 4: Seek Training and Certification (Optional but Recommended).
Several organizations offer training programs and certifications for claims examiners. Certification can demonstrate your knowledge and skills to potential employers. Look into certifications offered by organizations like the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA). Visit the AAPC website and the AHIMA website for details.
Step 5: Apply for Claims Examiner Positions.
Search for open positions on job boards and company websites. Tailor your resume and cover letter to highlight your relevant skills and experience. Practice your interviewing skills so you can confidently explain your qualifications and interest in the role.
Step 6: On-the-Job Training.
Most employers provide on-the-job training to new claims examiners. This training typically covers company-specific policies and procedures, claims processing systems, and applicable regulations. Be prepared to learn continuously and stay updated on industry changes.
Step 7: Continuing Education.
The insurance and healthcare industries are constantly evolving. Continuous learning is helpful to stay current on new regulations, coding guidelines, and best practices. Consider attending workshops, conferences, and online courses to expand your knowledge and skills.
How To Network As a Claims Examiner
A strong network is important for career growth as a Claims Examiner. Building connections can open doors to new job opportunities, provide valuable insights into industry trends, and offer support and mentorship. This section explores practical strategies for Claims Examiners to build and maintain a helpful professional network.
One of the best ways to begin is through internships and entry-level positions. Many companies offer structured internship programs, providing hands-on experience and opportunities to meet experienced professionals. These early connections can become a valuable part of your network as you progress in your career. Even after securing a permanent position, attending industry conferences and workshops is beneficial. These events offer a chance to learn about the latest changes, meet others in similar roles, and exchange ideas. You can find information about industry events through professional organizations. Many of these organizations offer membership benefits, including access to networking events, job boards, and educational resources. For example, you can visit AHIMA's homepage to learn about industry events and certifications.
Continuing education is another good way to connect with other professionals. Consider attending workshops or earning certifications related to medical billing and coding. These programs can provide valuable knowledge and skills, and they also offer opportunities to meet and work with other professionals in the field. Online forums and social media groups dedicated to medical billing and coding are also useful. These platforms allow you to connect with others, ask questions, share information, and participate in discussions. LinkedIn is a great platform for finding relevant groups and connecting with professionals in your industry. Remember to be active in these groups and contribute valuable insights to build your reputation and expand your network.
Actionable Tips & Resources For Aspiring Claims Examiners In 2025
So, you're interested in becoming a claims examiner? Great choice! It's a field with good job security and the opportunity to really help people get the benefits they deserve. This section will give you practical advice and resources to help you get started in 2025.
First, education is key. While a bachelor's degree isn't always mandatory, it can significantly boost your chances of landing a job. Consider degrees in healthcare administration, business, or finance. Coursework covering medical terminology, coding, and insurance principles will be invaluable. If a four-year degree seems too long, look into associate's degrees or certificate programs focused on medical billing and coding. Many community colleges and vocational schools offer these programs.
Next, gain practical experience. An internship is a fantastic way to get your foot in the door. Look for opportunities with insurance companies, hospitals, or third-party administrators. Even volunteer work in a medical office can give you exposure to healthcare processes. Focus on developing skills in data entry, communication, and problem-solving.
Continuing education is also important. The healthcare industry is constantly changing, so you'll need to stay up-to-date on new regulations and coding guidelines. Consider obtaining certifications like the Certified Professional Coder (CPC) from the AAPC or the Certified Coding Specialist (CCS) from AHIMA. These certifications demonstrate your knowledge and commitment to the profession. Explore the websites of AAPC and AHIMA for more information.
Finally, network! Attend industry events, join professional organizations, and connect with people on LinkedIn. Building relationships with others in the field can open doors to job opportunities and provide valuable mentorship. Start building your network today!