A Medical Claims Analyst works in the insurance industry to determine levels of reasonable and necessary charges for all medical claims. These are then used when ascertaining which costs will be covered by a medical insurance policy.
A Medical Claims Analyst is responsible for maintaining "cost containment" for their employer, usually an insurance company. Cost containment is basically the ability to keep costs (payout for medical insurance claims) to a minimum in order to provide a reasonable profit for the insurance company.
In order to determine whether specific medical/surgical bills are reasonable and necessary, an analyst evaluates what the "usual and customary" billings are; these are then used to determine what amount will be paid when a claim is filed. Items which are reviewed and analyzed may include: length and appropriateness of hospital stay, surgical procedures, claims referred for medical management, appropriate follow-up physician visits, and similar items.
Analysts may also perform a second review of claims which have been denied in whole or in part to determine the appropriateness of the payments authorized, or interpret the Workers' Disability Compensation Act to determine eligibility. They may also be required to attend hearings or mediation to defend the decisions made if they are disputed.
Analysts prepare reports and records which analyze and interpret data related to claims quality of service, as well as produce forecasts of claim receipts.
Most Medical Claims Analyst jobs require a bachelor's degree in nursing, physician assistant, pharmacy, or business administration or the equivalent combination of education and experience with several years claims analysis experience.
A working knowledge of medical billing claims terminology, and the medical claims process is necessary. In addition, a strong base in mathematics and statistics is desirable.
After working at an entry level analyst job for several years, a typical career path would be to become a lead supervisor over a group of analysts, perhaps eventually promoting to senior supervisor over a department.
With the healthcare industry experiencing greater than average growth, these jobs should continue to offer good long term potential. In addition, with the potential of the new national healthcare system, more analysts may be needed to ensure the appropriate levels of care are met.
Medical-Claims Analysts make an average of $53,000, with a range of mid $40k to low $60k. Differences depend on geographical location and experience.
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